Job description

• Promotes the mission, vision, and values of the organization
• Establishes, reviews, and updates short and long-term goals in order to be consistent with facility wide plans
• Establishes specific and necessary planning, control and performance improvement mechanisms that monitors patient care, administrative and economic outcomes
• Directs the overall activities of the Medical Record Department by establishing specific necessary planning; maintaining, training and evaluating sufficient staff; developing and maintaining control mechanisms that monitor patient care and administrative and economic outcomes
• Directs the activities of personnel under their supervision
• Maintains sufficient, trained staff to adequately fulfill the requirements of the department
• Organizes department hierarchy/structure in a manner that results in efficiency, effectiveness and responsiveness
• Maintains a sensitive, fair, and impartial approach to dealing with employees
• Develops and maintains channels of two-way communication with employees and performs departmental in-service training
• Establishes and monitors standards of performance through ongoing counseling, coaching, delegation, and feedback practices
• Conducts department-wide meetings to maintain two-way communication, problem solving, and information passing
• Performs internal chart audits
• Maintains an appropriate turnaround time for coding, transcription and release of information
• Ensures the quality of medical records by verifying their completeness, accuracy, and proper entry into computer systems
• Codes or supervises coding for all patient types, both in-house and out-sources
• Provides sufficient training and sets standards of proper coding to retain maximum reimbursement
• Directs coding audits as necessary
• Maintains specific and necessary controls to ensure confidentiality of patient medical records
• Strictly adheres to HIPAA policies
• Assumes the responsibility for successfully fulfilling standards and criteria of licensing and accrediting agencies
• Stays abreast of regulatory requirements, coding and reimbursement changes
• Maintains regulatory requirements including all state federal regulations
• Interacts with other departments within the hospital to ensure the quality and completeness of patient medical records
• Interact positively with members of the medical staff by cultivating liaisons and promoting interaction
• Attends meetings, prepares reports and analyzes and provides recommendations in a timely and accurate manner
• Maintain regulatory requirements, including all state, federal and local regulations
• Represent the organization in a positive and professional manner at all times
• Comply with all organization policies and standards regarding ethical business practices
• Communicate the mission, ethics and goals of the organization
• Participate in performance improvement and continuous quality improvement activities
• Attend regular staff meetings and in-services
• Other duties as assigned

• Registered Health Information Administrator or Registered Health Information Technician
• Minimum of five years’ experience in Health Information Management, preferably in a hospital setting
• Extensive knowledge of HIPPAA required
• Previous hospital experience preferred
• Electronic medical record knowledge
• Previous HER administration experience preferred
• Coding knowledge ICD-10 Knowledge, Skills, and Abilities
• Knowledge of health information management services
• Strong organizational and interpersonal skills
• Ability to determine appropriate course of action in more complex situations
• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work
• Ability to maintain confidentiality of all medical, financial, and legal information
• Ability to complete work assignments accurately and in a timely manner
• Ability to communicate effectively, both orally and in writing
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner

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