Director of Health Information Department

Director of HID Job Description

Position: Director of HID

Department: HID

Pay Status: Hourly

Supervisor: Chief Operations Officer

Position Summary: Leads and monitors the day to day operations of the Medical Records Department of the hospital. Responsible for providing oversight for the timely filing & entering of documentation into the patient’s medical record; responsible for enforcing confidentiality & security of the medical records; works closely with Dept. Managers to facilitate and manage the timely completion of medical records & required documentation; reviews documentation submitted for accuracy and thoroughness; provides reports & data to the CEO, DON, DCS, Medical Director, and other Dept. Directors, as required, in order to address deficiencies in a timely manner that supports compliance. Participates in PI Committee, Leadership Team meetings, UR.MR Committee and other committee meetings as required.. Provides oversight for the accurate coding of medical records for billing and other requirements.

Essential Functions:

• Department Overview: Responsible for the monitoring the integrity of chart documentation; , transcription/ transcription reports, the exchange of medical information between treating facilities/other requesting entities, filing of loose material, record copying, collection of discharged charts from the units, monitoring of all other HID duties and supervision of HID staff.
• Completes coding functions.
• Completes and distributes deficiency lists and provides monthly deficiency reports.
• Submits required reports for monthly committee meetings, as required.
• Audits charts/monitors the audit process and responds to deficiencies in real time. Submission of documentation.
• Keeps Hospital Leadership/Committees and Dept. Managers informed of the status of deficiencies in real time.
• Makes charts available for: Regulatory agencies & Accreditation entities., QA activities, Legal Issues, Risk Management
• Serves as the sole official repository for all approved forms.
• Oversees privacy and security functions for records. Maintains control of all medical records at the hospital and off sites and manages day to day access to said records.
• Assembles all formal external reports and oversees the submission of said reports (Oryx, NRI, etc.)
• Remains current with all standards that govern records keeping, dissemination, report building, and data submission.
• Attends all appropriate hospital meetings and presents HID information when appropriate.
• Is an integral part of the development of an electronic health record that covers all functions including reporting and billing support functions.
• Human Resources Competence: Demonstrates skills in organizing, leading and inspiring individuals and teams of people toward the pursuit of a common vision, goal attainment, and high performance in a continually changing environment; attracts diverse talent to the organization; coaches and develops others, and provides people the opportunity and encouragement to participate. Demonstrates knowledge of pertinent employment statutes, procedures, and policies. Has a knowledge and understanding of NBHS policies and procedures and consistently enforces those policies/procedures. Follows through in a timely manner addressing personnel issues both verbally and in writing to employees and consults with HR regarding personnel matters.
• All other duties as assigned.

Minimum Qualifications:

Education: Degree in a health related field preferred and knowledge or specific training in medical or health care records.

Experience: A minimum of three (3) years’ experience in a health care industry preferred; Knowledge of medical records requirements; extensive knowledge of HIPAA and protected health information; knowledge of state, federal and TJC requirements for medical records maintenance and completion

Age – specific Competencies: Child & adolescent preferred

Licensure/Certification: American Health Information Management Association Member and Certificate required

Other Required Knowledge/Skills/Abilities: Basic fiscal management skills; thorough familiarity with business & health care terminology; excellent written and oral communication skills; knowledge of, and skills in reviewing & completion of a medical record; creativity; flexibility; time management and organizational skills; skills in data collection and analysis, interpretation, application, and evaluation; strategic planning skills; record of adherence to deadlines; customer service skills; teaching or training skills helpful; Skills in maintaining information as highly confidential.

HIPAA: Has access to all PHI necessary to perform job functions of managing and directing Medical Records department and assuring compliance with standards of care.

Work Demands/Environment:

Ability to stoop, kneel, crouch, reach, push, pull and lift; ability to finger (e.g. pick, pinch, type) and grasp; ability to express and exchange ideas by spoken word in an accurate, audible, and occasionally quick manner. Ability to perceive sound with no less that a 40 db loss @ Hz, 1000 Hz and 2000 Hz with or without correction and to make fine discrimination in sound; ability to perform substantially repetitive motions of the wrist, hands, and fingers; ability to perform substantially sedentary work, exerting between 10 to 20 pounds of force; ability to lift or move objects. The worker is subject to some temperature changes but is largely protected from changing weather conditions.