RIDEOUT HEALTH POSITION NUMBER: 000 EFFECTIVE DATE: APPROVED BY: RESPONSIBLE TO: SVP & CIO RESPONSIBLE FOR: The HIM (Health Information Management) Director is responsible for leading and directing health information management services across the multi-facility integrated healthcare delivery system; striving for compliance and promoting best practices and education in all areas. EXEMPTION STATUS: Yes KNOWLEDGE: Experience with the electronic health record, health information systems and healthcare applications. Experience with regulations and accreditation standards, knowledge of specific state and federal requirements and standards related to the management of health Information Maintain professional relationships with state and national organizations to gain insight and understanding of future trends, regulations, etc. Expertise in healthcare compliance: knowledge of privacy and security regulations, confidentiality, laws, access and release of information practices Expertise in health information management, best practices, processes and procedures. Knowledge of medical terminology, classification systems, and vocabularies. Demonstrates leadership skills and exercises judgment within generally defined practices and policies when selecting methods and techniques in problem solving. Takes the initiative to make decisions and is an advocate for change. Knowledge of 3M Encoder and McKesson Patient Folder will be an advantage. SKILLS: Master's, Bachelor's, or Associate's Degree in Health Information Management or related field EXPERIENCE: Minimum 5-10 years’ experience in Health Information Management in an Acute Care Hospital LICENSE: RHIA or RHIT Credential required DEFINITION: The HIM (Health Information Management) Director is responsible for leading and directing health information management services across the multi-facility integrated healthcare delivery system; striving for compliance and promoting best practices and education in all areas. RESPONSIBILITIES: Daily Operations Develops and oversees processes in the HIM Department: ensures that HIM processes and controls are evaluated against the organization's internal and external information needs on an ongoing basis Actively participates in various committees such as, but not limited to, the Medical Staff/Medical Records Committee, hospital-wide Performance Improvement Committee, Documentation Improvement Committee, and enterprise-wide Electronic Health Record related Committees. Responsible for initiating, reviewing, implementing, and maintaining contracts with vendors for outsourced HIM services. Takes steps to actively move forward from paper based health record to a fully integrated electronic health record environment. Ensures that information systems support current and future needs of the department. Works closely with information technology in transition planning including, but not limited to, testing, installation and education of staff to produce and maintain high quality data integrity. Works with risk management, legal counsel, and administrative staff, key departments and committees to ensure that the organization has and maintains appropriate compliance including privacy and security and confidentiality policies, procedures, forms, information notices, and materials which reflect current organizational practices and regulatory requirements Instrumental in form/template design for the electronic health record. HIM professionals should be working actively with IT to develop forms to enhance high quality data collection. Ensures compliance with external agencies and state and federal regulations. Develops, maintains, and implements policies and procedures; evaluates and improves the effectiveness of policies and procedures and work flow Serves as an internal consultant on health information management issues including release of information, confidentiality, information security, information storage and retrieval, and record retention as well as authorship and authentication of health record documentation, standardization of medical vocabularies, and use of classification systems Strategic Planning Develops departmental services through ongoing planning which is consistent with the organization's mission, vision and values as well as the organizational objectives outlined in the strategic plan; establishes, coordinates, and communicates departmental objectives and goals as well as organizational goals Designs and maintains the physical environment by organizing personnel and equipment within the space and budget available; arranges the physical environment to facilitate smooth workflow; optimizes space efficiency to ensure safety Prepares and utilizes the annual operating budget for the Health Information Management Department and capital expense requests. Submits all annual budgets completely and in a timely fashion Monitors spending: Routinely evaluates monthly productivity levels against target staffing levels and makes necessary operational adjustments to meet goals Ensures resources are appropriate for departmental staff to meet job demands; considers future services and projects the budget accordingly Educates employees about financial goals and objectives in ways which encourage ownership and personal Accountability Quality Management Monitors productivity and quality standards according to department and organizational guidelines and monitors staff adherence to these standards on a routine basis Participates in the monitoring, evaluating, educating and improving the quality of health information Identifies problems, tracks trends, and initiates actions to improve performance towards achieving departmental standards Designs, performs, and appropriately utilizes the findings of performance improvement activities of health information services and follows up on both positive and negative quality improvement findings Compliance Monitors the initiation, revision, and implementation of external regulations, statutes, and standards; facilitates implementation of revised regulations; ensures conformance Interprets regulations for application and formation of facility policies. Writes and reviews policies to maintain compliance Cooperates with the Office of Civil Rights, CMS, other regulatory, accrediting and legal entities and organization officers in any compliance reviews, investigations or surveys Works collaboratively with risk management, department heads, IT, and HR to minimize the potential risk of privacy and security breaches, to mitigate damages if any, and to resolve related issues Initiates, facilitates and promotes activities to foster information privacy awareness within the organization Monitors local, national, and international trends in healthcare delivery Human Resources Management Staffs the Health Information Management Department sufficiently to provide efficient and effective services. Reviews and approves personnel matters pertaining to interviews, hires, and training for new employees. Reviews provisions for staff development, training, and orientations as prescribed by the organization and departmental standards. Directs staff training related to Patient Privacy and HIPAA Compliance; initial as well as refresher training ; Plans for staff shortages through cross training Implements a reporting system that incorporates a reasonable span of control including time and resource allowances to effectively perform services and communicate; organizes the department in such a way that decisions are made and problems are solved at the appropriate level Fosters a strong working relationship between medical staff, administration, and HIM personnel Motivates and empowers staff in the successful performance of their tasks and responsibilities to support the organizational needs and encourages innovation. Provides education and guidance to clinical staff transitioning to the electronic health record. Supports credentialed and supervisory staff in their continuing education efforts and encourages and provides continuing education for all department employees through in-service programs, meetings, or other opportunities for professional growth Maintains adequate dialogue with direct reports and employees and maintains at least monthly staff meetings. Make formal and informal presentations both orally and in writing. Provides direct reports with the resources, tools and training they require to meet expected performance levels. Provides feedback on direct report's performance and makes recommendations for improvement Utilizes results of quality control monitoring as an integral part of employee performance appraisals; Monitors, evaluates, appraises or disciplines employees activities according to organizational I standards PERSONAL RESPONSIBILITIES: Maintains personal responsibility in awareness of federal, state, legal and accrediting regulations. Knows and upholds hospital and departmental policies. Contributes to the time management of the department by being punctual to work and prepared to work according to the department and hospital standards. Appropriate usage of sick leave per hospital policy. Uses good body mechanics in performing assigned duties and reports injuries in a timely manner. Promotes a professional image by adhering to established Dress and Grooming Polices of the hospital and the Department. Maintains confidentiality of all departmental and hospital information according to established procedures. Maximizes job potential by attending all mandatory education and in-service programs as indicated by attendance records, CEU’s and completes all read and sign information in a timely manner. Demonstrates an ability to set appropriate priorities, functions in an organized and time conscious manner. Maintain license and/or certification, specific to their profession. INTERPERSONAL RESPONSIBILITIES: Recognizes when others are in need of assistance and consistently offers help when own workload permits or finds someone who can. Interacts in a courteous, positive and professional manner with co-workers, medical staff, patients and visitors to effectively coordinate departmental activities for overall hospital function. Informs supervisor of activities and changes that affect the operations of the department. Attentive to others points of view, recognize that their concerns are real and demonstrate capability to encourage two-way communication. Demonstrates willingness to provide the highest quality service appropriate based on the concept, philosophy and goals and improving organizational performance of the Fremont-Rideout Health Group.