Supervises and backs-up a facility-wide, efficient Health Information Management Program and staff.
Monitors health information management systems and sets the standard for data quality and ethical practice.
Responsible for ensuring the centralized coding team receives all discharged records for appropriate coding/indexing purposes.
Responds to requests for medical records, including legal and court cases, following applicable state and federal laws concerning the confidentiality of medical records; possesses knowledge of those populations to respond with appropriate communication, medical terminology for appropriate assessment, treatment planning and discharge planning needs as it applies to thoroughness of the medical record.
Responsible for ensuring all transcribed reports are complete, accurate and on the patient records.
Supervise all activities and maintain overall responsibility relative to documentation, usage, retrieval and storage or all inpatient and outpatient records.
Participates in the development of health information management policies and procedures.
Provides education and training to the hospital’s employees in areas relevant to health information management policies and procedures.
Collects data and prepares monthly statistical reports as requested.
Assures the timely completion, integrity, authenticity and accessibility of all inpatient and outpatient medical records by placing discharged charts in accepted chart order; analyzing each chart to assure completion of all necessary information; routes charts to individuals who need to complete deficiencies found; Assures immediate access of any chart or any particular type of chart using acceptable filing, coding and indexing procedures and deficiency slip tracking system.
Participates in Performance Improvement (PI) process by monitoring specific standards of excellence in discharged medical records through discharge chart deficiency slips; reporting any deviations of accepted practice to the PI Committee; attending PI Committee functions; compiling necessary reports and reporting results to PI Committee.
Performs other duties and projects as assigned.