Job Description

Responsible for supervising, coordinating, administrating and monitoring the HIM activities related to Clinical Coding. Also responsible for ensuring the effective management and implementation of the organization’s policies and that the HIM services are provided according to approved policies and procedures, regulatory requirements and accreditation standards. Responsible for system and process innovations in the HIM department, in cooperation with other Senior Officers, as well as handling personnel responsibilities such as staffing, training, monitoring and performance evaluations.

Responsibilities

• Ensuring the coordination and integration of Health Information Management services with other departments
• Ensuring adherence to agreed service level agreements for internal and external customers
• Making recommendations to improve efficiency of services.
• Making recommendations to HIM Manager regarding the departmental needs
• Organizing, supervising and controlling the daily activities and work processes in , clinical coding, statistics, chart analysis & delinquency reporting and areas in accordance with facility policies and procedures.
• Safeguarding the integrity of medical records of medico-legal relevance and medical records that are of potential medico-legal implications.
• Consults with Head of Department and other senior staff appropriately to assist in correcting problem areas and improving services.
• Monitor HIS functions specific to Coding and report issues to facility HIM-IUC representative for trouble shooting and resolution.
• Producing productivity and statistical data and reporting on daily monthly and adhoc basis for management and key department/sections as per instruction from HIM Manager
• Assist medical research and review programs by providing data and records adhering to the policy and procedure
• Assisting and identifying the insufficient or ambiguous documentation issues and reporting to the HIM Manager or physician whenever required
• Informing the HIM Manager , regarding problems related to completion of incomplete charts,analyzing the routine discrepancies in the system and suggesting ways to solve those discrepancies
• Ensuring that the coding and analysis functions are performed on daily basis.
• Ensuring that coding is performed as per the regulatory and accreditation standards, guidelines and policies.
• Ensure coding supports claim submissions and data management activities
• Ensuring continue education to the staff by recommendation to the HIM Manager
• Promote confidentiality among the staff and conduct security audits when required
• Maintaining staffing, work schedules and time keeping records
• Applying the policies of the facility in relation to attendance, annual leave and sick leave
• Planning, allocating, checking and evaluating staff work through out the day
• Ensuring motivation and supervision of staff daily to ensure that the deadlines are met and workload monitored
• Making recommendations to the Manager regarding the staff, equipment and supply needs
• Ensuring appropriate accountability and adherence to approved budgets
• Analyzing monthly variance reports on budgets and authorizing all required expenditures and supplies are made in a timely manner in order to ensure smooth functioning of the department
• Overseeing day-to-day integrity of database and database procedures, which may include conducting weekly and monthly audits of data, to confirm use of accurate entry processes
• Identifying and eliminating duplicate records both paper and electronic by checking the master patient index and coordinate with HIM IUC and SSMC HIS team for the modification and combining of electronic MPI data in the facility and enterprise level.
• Archiving of records with no activity for specified period by following the facilities retention policy and procedures and regulatory standards.
• Monitoring and maintaining users’ security settings in HIS
• Conducting frequent audits of electronic medical record using the application tools as per the instruction of HIM Manager / Senior Management to detect breach of confidentiality and patient privacy issues.
• Producing productivity reports and statistical data and reporting on a daily, monthly and adhoc basis for management and key departments/sections
• Utilizing specified HIS applications to analyze and interpret research data, as appropriate to the individual position.
• Coordinating with HIM IUC and SSMC HIS team, for creating reports in HIS for HIM related sections and to report data to the hospital management and regulatory agencies.
• Directing, preparing and distributing health information (electronic and paper) to relevant departments within the facility while ensuring accuracy and timeliness of the same
• Overseeing the retrieval and modification of patient information from the health information system while strictly adhering to patient privacy and confidentiality guidelines and accreditation and regulatory standards.
• Coordinating with outsourced Coding services where required to ensure that all the patient encounters are coded and updated
• Ensuring timely analysis, notification and completion of medical records as per the facilities chart completion policies and procedures, regulatory and accreditation standards.
• Reporting defaulters to the HIM Manager for recommending disciplinary actions as per the facilities policy and procedures.
• Ensuring training and orientation to new staff and ensuring that employees adhere to the departmental and facility policies and procedures
• Identifying any opportunities for staff training and development
• Coordinating staff meetings to discuss the issues pertaining to the workflow of specific areas of responsibility
• Monitoring the quality of work of the department/section and participating in department/sectional quality improvement initiatives
• Investigating and resolving problems, complaints and incidents from internal and external customers and resolving the same
• Improvising policies, processes and guidelines to initiate systemic changes for better functioning of the department
• Participating actively in the clinical audits of the department
• Participating actively in risk management initiatives and evaluating data management risks and taking preventive measures
• Monitoring the accuracy and quality of various data, reports and statistics produced by the Health Information department
• Ensuring completeness and accuracy of data available within the system
• Ensure completeness and accuracy of documentation
• Ensure the process of monitoring of coding data for accuracy through regular internal and external coding audits
• Maintaining collaborative and effective relationships with other key management
• personnel and keeping abreast of significant economic, social and technical trends, and regulatory guidelines, which may influence assigned functions/services and/or the facility
• Providing and maintaining effective liaison and relationships with other department/sections, the clinical staff, patients, legal counsel, and other agencies that interface with the department/section
• Maintaining the confidentiality of all health information and ensuring that the staff are aware of the need for confidentiality
• Resolving problems that arise with releases of confidential medical information, misplaced patient records or any other client facing problem
• Ensuring high quality of customer service, communicating and maintaining the performance expectations of clients
• Identifying and recommending ways to improve client satisfaction within the department
• Participating in cross-functional teams and committees as appropriate
• Managing his/her subordinates and ensuring team development and complaint resolution, setting Key Performance Indicators for direct reports, conducting performance appraisals and driving motivation levels of direct reports
• Developing and maintaining positive and constructive work relationships with departmental and facility staff
• Maintaining staffing, work schedules and time keeping records
• Applying the policies of the facility in relation to attendance, annual leave and sick leave
• Planning, allocating, checking and evaluating staff work through out the day
• Ensuring motivation and supervision of staff daily to ensure that the deadlines are met and workload monitored
• Listening to staff grievances and taking appropriate action
• Undertaking people responsibilities such as staffing, performance management, disciplinary action and termination of staff under span of control
• Ensuring accurate coding and sequencing as specified by established coding principles and guidelines, following the clinical coding system
• Allocating the appropriate and specific codes from the indexing system and assigning the codes for completing coding summary of the medical records
• Assisting with the preparation of medical records for the quality assurance and medical audit purposes by providing the coding data
• Investigating and resolving problems, complaints and incidents occurred within the coding section, and reporting these occurrences to the HIM Manager for further action, as required.
• Validating that encoded information is reported with mostaccurate information
• Updating coding section with regard to all changes in regulatory requirements

Qualifications

Required:

• Bachelor’s degree in Health Information Management or Diploma with 3 years of additional experience

Desired:

• Master degree or equivalent in Health Information Management

Specialist Certifications:

Required:

• Recognized coding and /or HIM certification such as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Health Information Manager (CHIM) Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Professional Coder (CPC)

Desired:

• N.A

Experience:

Required:

• 4-6 years of relevant progressive experience in a similar role

Desired:

• Previous coding experience as a supervisor in a large Healthcare facility with knowledge of DRG and billing, statistics