JOB SUMMARY

This position is responsible for managing, supervising and planning all functions of the Health Information Department as well as supporting the organization and its' patients through the provision of complete and accurate medical records.

PRIMARY JOB DUTIES

Adheres to Brodstone Healthcare Mission, Vision and Values. Adheres to Brodstone Healthcare Standards of Behavior. Shall be familiar with all functions of the 3M Encoder as needed to perform job and direct coding staff. Ensures that proper

ICD-10-CM

coding rules and regulations are completed for inpatient and outpatient charts, proper CPT coding for outpatient procedures as required, and reviewing the assigned DRG that is generated for completion of the UB-04 billing form by the business office. Ensures statistical information is compiled and reports are submitted as required by regulation or policy. These reports include but may not be limited to: Nebraska Hospital Statistical Reports, Cancer Registry, NORS (NE Organ Retrieval System), Birth Certificates, Birth Defect and Trauma Registry. Maintains a list of incomplete charts to notify providers of charts needing dictation as required on a day to day basis. Responsible for the HIM QI Plan and monthly data collection, scheduled reporting, and annual review of plan. Assists the Quality Management Department in the Medical Staff QI studies as requested. Active member of and regularly attends scheduled meetings of the following: EHR Steering Committee, Revenue Integrity, Department Head and other meetings as assigned. Prepares, schedules and conducts monthly HIM department meetings. Records attendance and minutes of these meetings. Responsible for assisting the Education Department with staff programs, continuing education and skills training programs for the HIM Department. Create and annually review the job descriptions for the department. Create and annually review the department policies and procedures according to the organization policy. Assumes responsibility for hiring, training, coaching and evaluating HIM Department employees. Responsible for employee scheduling and payroll obligations. Ensure that accurate medical records are maintained and provide for their safekeeping, availability, security and retention as directed by Federal, State and facility policy. Monitors medical records for compliance with Federal and State laws and regulation; ensures that medical records meet standards for reimbursement by third-party payers and for audits; responds to requests for release of confidential patient medical records in accordance with laws and regulations; and completes surveys of medical records requesting statistics and data related to medical records. Ensure that proper information is relinquished to insurance companies when requested. Attends continuing education training to maintain credential as a Registered Health Information Administrator or Registered Health Information Technician. Attends and participates in other organizational meetings / in-services, Brodstone Healthcare quality improvement program, etc. as assigned. Assists in performance of internal Compliance Audits as assigned. Performs other duties as assigned.

EDUCATION

Required Associate's degree (Health Information Management) Preferred Bachelor's Degree (Health Information Administration)

EXPERIENCE

Required Minimum of one year of experience in a Health Information Department.

ICD-10CM

Coding and CPT Coding Transcription of medical dictation Medical Terminology

CERTIFICATE, LICENSES, REGISTRATIONS

Required RHIT Preferred RHIA Join Brodstone Healthcare and have a lasting impact on Rural Nebraska!