Job Requirements

General Summary:

Leads, directs, monitors, and is responsible for the successful operations of Health Information Management (HIM) for the University of Maryland Medical System (UMMS). This position will serve as the HIM Sr. Director of Entity Support. The primary objective for this role will be to oversee all affiliate UMMS HIM Departments in the following areas: medical record processing and completion (Chart Analysis), document imaging with de-centralization oversight, forms management, transcription, voice recognition, release of medical record information, record storage and retrieval, collection and compilation of birth and death certificate information, compliance with activities related to development, implementation, maintenance of and adherence to policies and procedures governing the privacy and access to patient information in compliance with federal and state laws and UMMS Notice of Privacy Practices. Also, responsible for compliance with state and federal agencies as well as The Joint Commission, (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF) and any other accrediting agencies pertaining to medical record keeping. Responsible for developing and implementing operational and capital budgets in conjunction with the departmental management teams. Ensure standardization of HIM policies and procedures to achieve excellence in service delivery and outcomes that are in alignment with UMMS strategic plan and key operational goals.

Principal Responsibilities and Tasks:

1. Establishes leadership and ensures ownership within the HIM function at all UMMS Affiliates for clinical information, ensuring HIM is the primary contact source or area for patient related medical record information, including information stored digitally, on microfilm, paper or electronically; and ensures the standardization of storage, content, and retrieval of medical record information across all settings of care.

2. Manages all HIM operational initiatives and the agenda for change within the HIM department and services shared with other UMMS Affiliates ensuring alignment with the organization's strategic objectives. Analyzes data and develops cost effective staffing models to ensure the delivery of HIM solutions.

3. Prepares and administers operational and capital expenditure budgets for the department, incorporating long and short-range goals, and forecasting personnel and equipment needs. Monitors departmental expenditures to assure fiscal responsibility and accountability.

4. Establishes and implements a framework for the development of written standards within the HIM department, and facilitate standardization of HIM policies and procedures for all other UMMS Affiliate hospitals' HIM departments for duties they are responsible for.

5. Evaluates statistical data regarding operating efficiency received from management staff to ensure efficient and accurate work flow, staffing patterns and operating systems through systematic feedback mechanisms.

6. Will oversee staff that will support physicians in any area needed related to record completion and transcription. Will also assist hospital and Medical Staff leaders in design and maintenance of clinical software programs.

7. Oversees the development and maintenance of adequate internal and external communication systems for the HIM department by coordinating and integrating the efforts of the department with those of other ancillary departments such as, medical staff, nursing, administration and allied health staff to achieve institutional goals, as well as, departmental goals, including completion of medical records through educating physicians and other professional staff regarding documentation standards, providing transcription and record analysis education and monitoring and reporting compliance guidelines.

8. Directs and oversees current state and federal legislative changes and new related hospital policies. Communicates changes, protocol and procedural revisions to ensure implementation of updated guidelines through legislation to the appropriate department for operational changes to ensure compliance.

9. Serves as a subject matter expert for Hospital and Medical Staff leaders regarding standards of documentation for CMS Conditions of Participation, TJC Standards, and CARF related to Health Information Management.

10. Ensures that audits are completed as required by the internal Quality Improvement/Joint Commission Committees and reports findings. Ensures that items are reviewed according to The Joint Commission standards and provides additional focused reviews as appropriate. Makes recommendations for improvement and coordinates improvement activities as requested.

11.Leads and participates in the development and implementation of institutional policies and procedures, such as policies on privacy and security of patient medical information. Partners with the Corporate Privacy Officer to assure compliance with HIPAA regulations regarding patient privacy, protection and appropriate release of PHI; leads investigation and responds to complaints related to privacy and release of information issues.

12. Participates with Hospital and Medical Staff Leadership to meet documentation, reimbursement and patient satisfaction standards in all HIM departmental activities as they relate to CMS. TJC, CARF, and any other accrediting agencies by providing timely information to committees.

13. Directs and provides effective leadership to perform the analysis for the completion of medical records with timely and accurate reviews of the medical record within the Epic System.

14. Directs and provides effective leadership to ensure processes are in place for all UMMS affiliates to facilitate timely and accurate imaging /scanning of paper medical record information into the imaging system and Epic.

15. Directs and provides effective leadership for the coordination of the dictation and transcription functions/processes for the Medical Staff, to ensure timely and accurate turn-around times on dictated reports.

16. Directs and provides effective leadership and oversight for all UMMS affiliate locations for reviewing, approving, posting and tracking forms used for clinical documentation and downtime processes. All Forms committees will be maintained on the local level.

17. In Entities where applicable, directs and provides effective leadership for the collection and compilation of Birth Certificate and Birth Defect information for submission to the Vital Statistics Agency according to state regulations. Ensures that the Medical Staff is assisted with the completion of Death Certificates and facilitates autopsies, if necessary

Work Experience

Qualifications:

1. Bachelor's degree in Health Information Management or a combination of relevant education and experience in Health Information Management (HIM). Master's degree preferred.

2. Current certification as a Registered Health Information Administrator (RHIA) or Registered Heath Information Technician (RHIT) through the Health Information Management Association is preferred.

3. Minimum of seven years' experience in a HIM Director role, preferably in a teaching or large hospital system.

4. Knowledge in the following areas required, HIM operations, including, but not limited to Chart Correction, Chart Analysis, Auditing and Chart Tracking, Document Imaging and Transcription.

5. Thorough knowledge of Health Information Management operations and applicable metrics and financials including improvements and impact on operating margins.

6. Proficiency in the operations and functions of HIM software systems, both from a user point of view and with ability to perform advance information and statistical analysis and report generation functions. Experience with the following software applications such as Epic and Perceptive are preferred.

7. Ability to oversee the operational budgets to ensure that they are aligned with organizational priorities and goals.

8. Expert knowledge of health information management pertinent to JC, CMS and CARF standards and related laws and regulations.

9. Strong standard of proficiency in directing, monitoring, evaluating and motivating the performance of professional management/supervisory staff.

10. Highly effective oral and written communication skills are required.

Working Conditions

1.Weekend, shift work, holiday, on-call, and overtime may be required.

2.Work is primarily performed in a high-volume medical office setting.

3.Traveling to multiple facilities may be required.