Health Information Management Supervisor, 40hrs/wk, Omaha

JOB DESCRIPTION

Job Title:  Health Information Management Supervisor MRSH-O 
Job Code:   880283
Immediate Supervisor: Director Health Information Management                       
Status:  Non-Exempt                      
 
DEPARTMENT FUNCTION/JOB OVERVIEW

Serve as the day-to-day operational supervisor for the Health Information Management Department.  Responsible for management, supervision and development of H.I.M. staff.  Responsible for operational functions including assessing and improving documentation practices, disease and procedure coding, confidentiality and release of information, record management and retention, and centralized document management.  Reviews and analyzes medical records to ensure documentation is accurate and complete. Responsible for generating data, completing and submitting reports in a timely manner to appropriate sources. Responsible for knowing state and federal regulations regarding medical records. Work will be performed in an ethical and legal manner following organizational policies, processes, and procedures. Responsible for quality service delivery and internal/external customer relations for Madonna as a whole, including upholding the mission and values for the department and facility.


ESSENTIAL FUNCTIONS

(INFORMATION)

1. Know and understand standards, regulations, and best practices regarding inpatient and outpatient medical records and implement processes to ensure compliance with these standards, regulations, and best practices. (Includes content and completeness of medical record, coding and indexing, confidentiality and release of information, record management and retention, etc.)
2. Coordinate, compile and analyze staff workloads to maximize efficiency of service delivery as well as to develop and implement contingency plans addressing occupancy and staff fluctuations.
3. Assist with preparation of medical records for review by others including:
4. Supervisors, managers and committees
5. Employee conducting quality assurance studies and research.
6. The Quality Improvement Organization
7. External accrediting/licensing agencies (NDHHS, CARF, etc.)
8. External financial auditing organizations
9. Any other legitimate request.
10. Appropriately collects data from multiple sources in order to complete files and reports.
11. Accurately prepares and types reports on a personal computer in designated format and in assigned time frames.
12. Performs audits of medical records to ensure accuracy and completeness.
13. Assist with documentation improvement strategies and sessions to include physicians, nurses, and therapists.
14. Maintains a working knowledge of state and federal regulations related to medical records.
15. Disclose protected health information appropriately, when requested.
16. Assist with filing documents in the appropriate paper medical record.
17. Assist with document scanning and indexing into the electronic medical record system.
18. Manage quality assurance processes for indexed documents.
19. Manage healthcare corrections process in the electronic medical record system.
    
     (PEOPLE)
20. Communicate with appropriate individuals regarding standards, regulations, and best practices for medical records and medical transcription.  Be diplomatic and persuasive in presenting the expectation of good patient record documentation for compliance, customer satisfaction and revenue generation.
21. Communicate with representatives of companies under contract to ensure effective performance of contracted functions, i.e. and off-site storage.
22. Supervise departmental staff to ensure compliance with policies and procedures release of information as well as goals and objectives.
23. Instruct and orient new staff to department goals, objectives, policies, procedures and Madonna's mission to ensure quality service delivery.
24. Routinely meet with staff to maintain open communication in regards to day-to-day operations, policies and procedures, goals and objectives to ensure quality service delivery.
25. Communicate with appropriate individuals regarding the results of documentation and coding quality reviews, including physician and therapist queries; must be diplomatic and persuasive in presenting the expectation of timely, concise, thorough documentation of diagnoses and/or symptoms to support services rendered.
26. Identify learning opportunities and provide education to case managers, physicians and other clinicians based on coding and documentation reviews.
27. Provide access to medical records to authorized individuals.
28. Answer questions about the medical record content or patient stays at Madonna to authorized internal and external customers.
29. Follows instruction from immediate supervisor to perform other functions as assigned in order to achieve the goals within the department and/or system.
    (THINGS)
30. Operate PC and software to review and/or enter master patient index information, diagnoses and procedure codes and clinical documentation.
31. Maintains a clean, organized and safe environment.  Handles and operates all necessary equipment and performs required duties according to established safety standards to maintain compliance with regulations and prevent injury.
32. Must be able to operate copier, telephone, fax machine and have proficient computer skills, including e-mail, document scanning, presentation, and spreadsheet functions.
    
    PHYSICAL DEMANDS AND ENVIRONMENTAL CONDITIONS
    
33. Sedentary work - lifting 25-30 pounds occasionally or lifting and carrying 25-30 pounds occasionally.
34. Indoor work - not exposed to outside elements or biohazards.
35. Near acuity and accommodation are required for reviewing the medical records and assigning ICD-10-CM and ICD-10-PCS codes.
36. Reaching, handling, and fingering and/or feeling are required for keyboard and mouse entry.
37. Requires sufficient sight to see and read reports and computer screen.  Requires sufficient hearing and speaking to communicate by phone or in person.
    QUALIFICATIONS (Education/training and/or Experience)
    
    EDUCATION

• Advanced education commensurate with eligibility for one of the following    credentials: RHIA (4 years beyond high school) or RHIT (2 years beyond high school.
  
  EXPERIENCE
• One year medical records/health information management experience in a lead role preferred.
• Experience with computerized patient records and personal computer applications preferred.
• One year ICD-10-CM and ICD-10-PCS coding experience with inpatient or outpatient records preferred.
  
  CREDENTIAL
• RHIA or RHIT attained or eligible and attained within 6 months of employment at Madonna.
  
  SKILLS - Required
• Extensive knowledge of contemporary medical records management functions and issues required.  Extensive knowledge of medical terminology, anatomy and physiology, disease pathology and coding principles.  Knowledge of Medicare and Medicaid regulations and resources. Must have excellent reading, grammar, and organizational skills.
  
  Background checks are conducted.  When specific authorization forms are requested so that full background and history can be obtained, emloyees/applicants must sign the form(s) requested.