HIM Coordinator | Stoughton

HIM Coordinator

The HIM Coordinator is responsible for the overall management of medical records, coding, and release of information and health information processes. The HIM Coordinator – is consistent with policies and procedures as set forth by accrediting and regulatory agencies. Performs other related duties as assigned or requested. This is a non-exempt position.

RESPONSIBILITIES

Operations

• SECURITY, CONFIDENTIALITY and RELEASE OF HEALTH INFORMATION: Safeguards the confidentiality of patient records from unauthorized review or release. Provides oversight for the prompt and appropriate release of information tasks. Keeps abreast of federal and state law. Responds to court subpoenas as custodian of medical records and presents records in court when deemed necessary.
• HIPAA (Health Insurance Portability and Accountability Act): Works to ensure compliance with HIPAA requirements. Participates in ongoing activities related to the development, implementation, maintenance of, and adherence to policy covering the privacy of, and access to, patient privacy practices
• CODING: Serves as the coding specialist and/or oversees the assignment of the appropriate ICD-10-CM diagnostic and procedural codes to individual patient information for data retrieval analysis and claims processing. Queries physicians and/or oversees the query process when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. Abides by the standards of ethical coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. When applicable, serves as key player in providing oversight in the appropriate assignment of Impairment Groups under the Preferred Payment System (PPS) for Rehabilitation and UDS data submission, as applies to rehab locations.
• REPORTING REQUIREMENTS: Timely submits required data to the Center for Medicare and Medicaid Services (CMS).
• CHART AUDITS/COMPLIANCE: Coordinates monthly interdisciplinary record reviews. Assists in performance improvement activities as recommended by QAPI Committee. Tracks, trends, monitors, and reports timeliness of physician documentation including the medical record delinquency number as per HIM policy/guideline to the QAPI Committee, MEC, and Governing Board.
• DOCUMENTATION AND RECORD COMPLETION: Works with clinical staff, physicians, consultants, nurses, therapists, etc., to ensure documentation is in compliance with hospital, accrediting, and licensing guidelines and provides ongoing education to staff. Strives to help ensure timely record completion. Reports deficiencies and record completion compliance to appropriate supervisors. Responsible for the monthly calculation of the record completion rate reportable to Joint Commission and presents the data at the Medical Executive Committee.
• STATISTICS: Assists in maintaining accurate hospital statistics. Provides specialized statistical reports as requested.
• OUTPATIENT PROCESSES: Provides oversight to the outpatient health information processes to include coding and documentation requirements.
Assists Administrator in other medical staff related functions. Assists in other functions deemed necessary or appropriate by Administrator and/or Corporate Director Health Information Management.

Leadership

• Inclusiveness: Promotes cooperation, fairness and equity; shows respect for people and their differences; works to understand
perspectives of others; demonstrates empathy; brings out the best in others and in his/her team.
• Managing Staff: Coaches, evaluates, develops, and inspires staff. Sets expectations. Recognizes achievements. Effectively manages conflict.
Aligns department goals with company goals. Provides feedback, group leadership. Delegates appropriately. Evaluations completed on time.
• Stewardship and Resource Management: Demonstrates accountability and sound judgment in managing company resources. Appropriate
understanding of confidentiality and company values. Adheres to and supports company policies, procedures and safety guidelines.
• Problem-Solving: Identifies problems, involves others in seeking solutions. Conducts appropriate analysis. Searches for best solutions.
Effectively and efficiently implements appropriate response to correct problem. Responds promptly and effectively to new challenges.
• Decision-Making: Makes clear, consistent decisions. Acts with integrity in all decisions. Distinguishes relevant from irrelevant information. Makes timely, appropriate decisions.
• Strategic Planning and Organizing: Understands company vision and aligns priorities accordingly. Measures outcomes. Uses feedback to redirect as required. Evaluates alternatives. Appropriately organizes complex issues to desirable resolution.
• Communication: Connects with peers, subordinate employees and all customers. Actively listens. Clearly and effectively shares information. Demonstrates effective oral and written communication skills. Negotiates effectively.
• Quality Improvement: Strives for efficient, effective, high quality performance in self and the department. Delivers timely and accurate results. Resilient when responding to matters that are challenging. Takes initiative to make improvements.
• Leadership: Motivates others. Accepts responsibility. Maintains high morale in department. Develops trust and credibility. Expects honest and ethical behavior of self and staff.
• Teamwork: Encourages cooperation and collaboration. Builds effective teams. Works in partnership with others. Is flexible. Responsive to the needs of others.
• Development: Maintains up-to-date skills through involvement with professional organizations or continuing education.

HIM Duties

• Assembles all records in accordance with approved record order. Records are assembled within one day after patient discharge.
• Accurately and timely analyzes records for completeness. Analysis is conducted within five (5) days after patient discharge. Enters deficiencies into HMS in a timely manner; tag incomplete charts and notifies clinicians of deficiencies; updates status in HMS when deficiencies are corrected.
• Assists healthcare providers in completion of their medical records, to include record accessibility. Provides accurate and timely deficiency notices.
• Aggressively works to maintain zero delinquent records. Takes initiative to creatively work with the healthcare providers to complete their records.
• Assembles patient folders; assists in maintenance of accurate MPI; assists with maintenance of accurate patient listing.
• Monitors record location and security, uses sign-out log, retrieves records after patient discharge. Demonstrates awareness of patient confidentiality and reminds others of same.
• Obtains all discharged inpatient medical records from nurses’ stations on a daily basis by 1:00pm.
• Verifies all demographic and MPI information, makes folder and completes all paperwork for chart on all new admissions; folder is always available for loose filing.
• Maintains ADT reports (HMS) and other census reports as requested by Director.
• Tracks AMA, LOA, deaths and any other information requested by Director.
• Provides oversight for the prompt and appropriate release of information tasks.

Department Support

• Has secondary responsibility for answering and routing incoming calls; takes complete messages.
• Orders all supplies from materials management. Informs Director of other supplies needed.
• Calls for service when fax or copy machine needs service.
• Distributes incoming faxes to appropriate departments or staff.

Customer Service

• Maintains the highest level of customer service via courtesy, compassion and positive communication.
• Promotes the Mission and Vision of Post Acute Medical within the work environment and community.
• Respects dignity and confidentiality by adherence to all applicable policies and procedures.

Health and Safety

• Works in a manner that promotes safety; wears clothing appropriate to the performance of the job.
• Participates in OSHA required training.
• Follows universal precautions as appropriate for position; complies with Employee Health requirements for continued employment.
• Reports unsafe practices to management.
• Knows own role in case of an emergency.

QUALIFICATIONS

Education and Training: Prefers the HIM Coordinator to be a graduate of a Health Information Management program with subsequent passing of the registry examination (RHIA) or accreditation (RHIT), but not required.

Experience: 1-3 years’ experience in a Health Information Management Department is required.

Knowledge, Skills, and Abilities:

• ICD-10-CM and CPT coding skills.
• EHR skills including but not limited to; prepping, scanning, indexing, and quality control.
• Computer literacy and the ability to type.
• Strong written and oral communication skills.
• Excellent organizational skills.
• Ability to prioritize.
• Ability to work with all customers.

ABOUT US

PAM Health is committed to being the most trusted source for post-acute services in every community it serves by utilizing experienced and dedicated staff to provide high quality patient care and customer service. With over 44 Long Term Acute Care and Rehabilitation hospitals and 16 Outpatient Clinics currently in operation across the country, we are proud to offer services including comprehensive wound care, aquatic therapy, ventilator weaning, amputation treatment, pain management and much more.

Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay, generous paid benefit time, and excellent insurance options, you will also have opportunities for professional growth through our Education Advancement Program.

We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online at www.postacutemedical.com for a comprehensive look at how we're able to positively impact our local communities.

PAM Health does not discriminate and does not permit discrimination, including, without limitation, bullying, abuse or harassment, on the basis of actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status, or based on association with another person on account of that person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.