Responsibilities Under the general direction of the Health Information Manager, effectively manages daily work flow in the Health Information Management department. Direct supervision of employees and workflow who handle chart processing, chart management, scanning, release of information, transcription, and coding. Assures ongoing efficiency in the various chart processing areas and training staff in regards to current procedures. Interviews and makes recommendation for the selection of staff. Assigns, coordinates, and oversees work, and reassigns work based on workload and absences. Coaches and trains all employees and conducts performance evaluations. Completes discipline documentation as needed, not to exceed level one without manager input. Ensures ongoing efficiency and timely receipt and processing of patient records as needed to assure proper storage and availability for continuation of care, medical research, studies, quality assurance and improvement, utilization management, and other authorized purposes. Assists with physician notification of incomplete records. Enters time and attendance records. Assists with special projects that impact the entire department. Extensive knowledge of JCAHO, legal and regulatory requirements impacting acute care and outpatient medical records. Analyzes/abstracts clinical information from medical records. Ensures appropriate ICD-9 and CPT codes are assigned to charts in accordance with a classification system to report diagnoses, operations, and procedures for reimbursement purposes, medical research, and healthcare planning. Enters data into computer system with great accuracy. Refers to AHIMA ICD-9-CM and CPT/HCPCS Procedural Coding Guidelines to ensure accuracy and consistency. Compiles statistical data as it relates to coding (i.e., DRG information, LOS, etc.). Performs DRG/APC audits, formerly summarizing results and submits to HIM Manager and CFO on a monthly basis. Follows-up on charts reviewed for medical necessity, performing an audit of the record; makes any necessary corrections as applicable and provides feedback as appropriate. Oversees and plans Documentation Improvement Program, working with Utilization/Case Management. Reviews weekly list of outstanding charts and follows-up on old accounts. Maintains highest level of confidentiality regarding patient health information. Education Requirements Associate's degree in Health Information Technology; or equivalent supervisory experience in Health Information Management. Bachelor's degree preferred. Registered Health Information Technician (RHIT) with eligibility for Certified Coding Specialist (CCS). Minimum Experience, Knowledge, Skill, and Ability Requirements Four (4) years of acute coding experience in a medical facility. Demonstrated leadership skills. Supervisory experience preferred. Expert knowledge of medical codes and health information management regulations. Excellent skills in using HIM software and working with IT staff on problems or changes. Excellent written and oral communication skills. Excellent analytical and problem-solving skills. |
