ESSENTIAL FUNCTIONS:

· Oversee and assist with data collection, storage, retrieval, assembly, analysis, filing and retention of medical records/data.

· Implement and maintain processes and systems to ensure accurate and complete medical record documentation.

· Maintain department productivity, quality and efficiency for all processes within the department.

· Oversee and assist with discharge records analysis for practitioner deficiencies and data for accuracy, compliance and timeliness.

· Work with physicians to improve the quality of documentation.

· Report practitioner trends and audit results to the Performance Improvement Committee.

· Complete HIM department audits including HBIPS, CMS Quality Measures, and concurrent reviews.

· Ensure documentation is filed in the medical records in an accurate and timely manner and ensure that the medical record is complete (including signatures) and closed within facility guidelines.

· Prepare and analyze clinical data for research purposes, process improvement, utilization management, mandatory reporting, and more.

· Ensure HIM Key Indicators are tracked and reported monthly to the Performance Improvement Committee.

· Ensure State Reporting is accurate, complete and reported timely.

· May oversee and/or complete coding according to current ICD and CPT coding classifications.

· Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

· May act as a liaison with legal and compliance on audits and court engagements related to HIM.

· Work as liaison between facility and transcription vendor to ensure high quality, accurate, complete and timeliness of transcribed documents.

OTHER FUNCTIONS:

· Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

· High school diploma or equivalent required. Bachelor’s degree with specialization in health information administration preferred.

· Two or more years' experience managing/supervising a medical records department required.

· One or more years’ behavioral health experience preferred.

· Knowledge and understanding of the CMS IPFQR (Inpatient Psychiatric Facility Quality Reporting) Program measures, documentation and reporting requirements required.

· Knowledge and understanding of The Joint Commissions HBIPS measures, documentation and reporting requirements required.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

· RHIT required or ability to obtain within six months of hire date. Certified RHIA preferred.