Description

The Health Information Management Director (HIM Director) provides coordination of Health Information Process. Prepare and maintain accurate medical records information according to established procedures within a medical records unit. Uses appropriate communication skills and knowledge of age/disability cultural diversity and provides emergency response, referred and assistive. All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and Performance Improvement Standards.

Essential Functions:

1. Supervises and backs-up a facility-wide, efficient Health Information Management Program and staff.
2. Monitors health information management systems and sets the standard for data quality and ethical practice.
3. Responsible for ensuring the centralized coding team receives all discharged records for appropriate coding/indexing purposes.
4. Responds to requests for medical records, including legal and court cases, following applicable state and federal laws concerning the confidentiality of medical records; possesses knowledge of those populations to respond with appropriate communication, medical terminology for appropriate assessment, treatment planning and discharge planning needs as it applies to thoroughness of the medical record.
5. Responsible for ensuring all transcribed reports are complete, accurate and on the patient records.
6. Supervise all activities and maintain overall responsibility relative to documentation, usage, retrieval and storage or all inpatient and outpatient records.
7. Participates in the development of health information management policies and procedures.
8. Provides education and training to the hospital's employees in areas relevant to health information management policies and procedures.
9. Collects data and prepares monthly statistical reports as requested.
10. Assures the timely completion, integrity, authenticity and accessibility of all inpatient and outpatient medical records by placing discharged charts in accepted chart order; analyzing each chart to assure completion of all necessary information; routes charts to individuals who need to complete deficiencies found; Assures immediate access of any chart or any particular type of chart using acceptable filing, coding and indexing procedures and deficiency slip tracking system.
11. Participates in Performance Improvement (PI) process by monitoring specific standards of excellence in discharged medical records through discharge chart deficiency slips; reporting any deviations of accepted practice to the PI Committee; attending PI Committee functions; compiling necessary reports and reporting results to PI Committee.
12. Performs other duties and projects as assigned.

Requirements

At least 1 year supervisory experience required and preferred 5 years psychiatric HIM department. Experience is required in the position to adequately perform duties and supervise staff. Must have one of the following: 1) Registered Health Information Administrator; or 2) Accredited Record Technician. High school diploma with additional training in Health Information Management, department functions (i.e. certified health information management technician or other such certification or training.

Extensive/broad knowledge is required for this position. Specifically, the ability to integrate information from all disciplines - from admission, nursing, physicians, administration, corporate, etc. - is a necessity. This position also requires broad knowledge in health information management, legal aspects relation to admissions and information releases, statistical compilation, computer, Joint Commission and Medicare Survey preparation. Must be Crisis Prevention Intervention certified, trained in SHARE, and must be able to pass general age/disability and cultural sensitivity post test. Must successfully complete CPR certification and an Oceans approved behavioral health de-escalation program.

Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.