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Responsible for strategic oversight and operational leadership of Coding, Clinical Documentation Improvement (CDI), and HIM Operations across a six-hospital integrated health system. Oversees all aspects of hospital coding operations, clinical documentation, and HIM operations, including Release of Information and Document Imaging departments. This senior role involves strategic planning, staff management, collaboration with clinicians and executives, and overseeing quality assurance and performance metrics.
Job Responsibility
Oversees the development and implementation of departmental strategy, goals, plans and standards consistent with the clinical, administrative, regulatory, and ethical requirements of the organization
Ensures overall adherence to MHS policies, governmental and regulatory requirements and accreditation standards
Responsible for providing operational leadership regarding the electronic medical record system and other HIM related applications, including computer-assisted coding, medical transcription and document imaging
Oversees the implementation and ongoing performance of the coder intern training program
Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements
Oversees HIM custodial responsibility for the storage, release, and confidentiality of the legal medical record in both paper and electronic formats
Provides professional expertise to the Privacy Department related to patient identity/fraud issues and patient requests for medical record amendments
Collaborates regularly with key stakeholders in the organization to promote communication, support revenue integrity, improve business processes, ensure reliability of internal and external reporting, and promote standardization across the healthcare system
Leads departmental operational and financial planning to ensure cost-efficient operations and to maximize profitability
Plans, organizes, manages and facilitates various budgets for HIM and Document Imaging including capital, operating, labor, and position control
Chairs the Legal Medical Record Committee and performs as an active member of various committees and work groups related to Privacy and Security, Compliance, Finance, Forms Management, Electronic Medical Record (EMR) Connect, EMR work groups, Nursing Informatics, Population Health, Quality & Patient Safety, and Revenue Cycle
Ensures patient data integrity overseeing patient identity, medical transcription, document scanning, deficiency analysis, release of information, and clinical documentation integrity (CDI) program
Provides leadership for hospital based inpatient and outpatient coding, clinical documentation integrity, coding and CDI education
Researches and monitors industry, professional and national developments related to HIM
Responsible for serving as project lead, advisor or sponsor for complex projects related to health information management operations
Develops and implements policies and procedures that guide HIM and Document Imaging business processes, support the delivery of services and ensure a culture of quality and patient safety
Oversees the planning and monitoring of onsite and remote staffing activities, including hiring, orienting, evaluating, disciplinary actions, productivity and quality monitoring, and staff training/education initiatives.
Requirements
Bachelors
Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)
Registered Health Information Technician (RHIT) - State of Florida (FL)
Ten (10) years of experience in a healthcare setting, with a significant portion in Health Information Management (HIM), clinical coding, and/or Clinical Documentation Improvement (CDI), including five (5) years in a leadership role.