Health Information Management Director

6 days ago

Windsor, North Carolina, United States LibertyHealth System Full time
Job Summary

We are seeking an experienced Health Information Management Director to join our team at LibertyHealth System. As a key member of our healthcare team, you will be responsible for overseeing the management of medical records and ensuring the highest level of quality and accuracy in our records management process.

Key Responsibilities
  • Department Head: Serve as the head of the Health Information Management department, overseeing the daily operations and ensuring that all tasks are completed in a timely and efficient manner.
  • Confidentiality and Ethics: Maintain a high level of confidentiality and ethics in all aspects of your work, adhering to strict standards of professionalism and integrity.
  • Room Rounding Program: Participate in the daily room rounding program as assigned by the Administrator, ensuring that all necessary tasks are completed and that patients receive the highest level of care.
  • Manager on Duty: Serve as Manager on Duty based on Department Head rotation schedule, as assigned by the Administrator, ensuring that the department is covered at all times.
  • Meetings and Communication: Attend all necessary meetings deemed appropriate by the Administrator, including stand-up, weekly Medicare and monthly/quarterly QA meetings, and communicate effectively with all stakeholders.
  • ICD-10-CM Coding: Assign ICD-10-CM codes upon new admissions, re-admissions, and interim resident stays, entering accurate codes into the facility's EHR system in a timely manner.
  • System Diagnosis Request: Process system Diagnosis Request, assigning ICD-10-CM codes based on Provider's signed documentation.
  • Maintenance of Medicare Certifications: Maintain Medicare certifications, sending a monthly report to the LHRS HIM Director.
  • Communication with Outside Agencies: Communicate with outside agencies for collection of necessary documentation, including documentation that requires signature.
  • Provider Visit Log: Maintain the Provider Visit Log, ensuring that each resident is seen timely by their Provider.
  • HIM Clinical Chart Audits: Complete required HIM clinical chart audits, reporting findings to appropriate staff in a timely manner and presenting findings during monthly/quarterly QA meetings.
  • Trend Summary Report: Submit a monthly trend summary report to the LHRS HIM Director.
  • EHR System Audits: Audit the EHR system to ensure that providers are signing e-orders and order reviews within the approved time frame.
  • Discontinued Medications and UDAs: Maintain the EHR update of discontinued medications and UDAs upon resident discharges.
  • Order Review Date: Update the monthly order review date within the EHR for new and readmissions.
  • Nursing Assessments: Set up baselines within EHR for nursing assessments.
  • DNR Notebook: Maintain a DNR notebook at each nursing station.
  • Scanning Documentation: Assist with scanning documentation into the EHR system.
  • Medical Record Storage: Maintain any remaining, on-site and/or off-site storage of medical record charts.
  • ARD Process: Coordinate the ARD process between facility and Corporate Management Audit & Appeals staff, including the copying and scanning of information.
  • Release of Information: Process non-financial Release of Information requests.
  • Provider Education: Assist as needed with educating Providers on the EHR Practitioner Engagement to ensure they have access and understanding of system functions and signing requirements.
  • Laptop Backup System: Complete daily checks to ensure the laptop backup system is functioning and upload log quarterly.
  • HIM Disaster Kit: Maintain the HIM Disaster Kit, including the facesheet notebook.
  • Emergency Procedures: In case of fire or fire drill, shut off all electrical equipment within the HIM office and report to designated areas. In case of evacuation, report to evacuation assembly areas and document patient arrival, pull the factsheet/diagnosis sheet binder from the HIM office to identify residents, and prepare the emergency packet, referring to the LHRS Disaster Plan Policy.
  • Other Duties: Perform other duties as assigned.
Requirements
  • Education: RHIA/RHIT, preferred or 3 yrs Long Term Care Medical Records experience required.
  • Certifications: Must have High school diploma or equivalent.
  • Computer Knowledge: Must have computer knowledge and experience.
  • Medical Terminology: Must have medical terminology knowledge.
  • Anatomy and Physiology: Must have Anatomy & Physiology knowledge.
  • Problem Solving: Must be able to work proficiently alone and work well under pressure and problem solve.
  • Collaboration: Must be able to collaborate well with other employees.
  • Appearance and Hygiene: Demonstrates neat appearance and good personal hygiene.
  • Clothing: Dresses with business attire appropriate for the work environment.
  • Policies: Must read, know, and follow personnel, department, and facility policies.
  • Driver's License: Must have a valid driver's license in the state of employment.

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