Independently uses own judgment and discretion to manage activities of the LTC HIM functions that include the planning and organizing of the documentation, storage and retrieval of resident medical records and monitoring to assure accurate and timely documentation of medical records.  Responsible for assigning ICD-10-CM codes for all LTC patient records in accordance with system and federal requirements.  Insures that all practices meet State and Federal regulations.  Oversees quality and productivity of the documentation and flow of the resident’s medical records in the active chart, the overflow chart and the discharged chart.  Assures HIPAA compliance in regards to the protection of the resident’s PHI.

1. Develops and maintains policies and procedures for the LTC resident medical record to assure compliance with State and Federal regulations.
2. Organizes and plans the LTC medical records department in accordance with established policies and procedures.
3. Assigns ICD-10-CM codes to all LTC patient records in accordance with DCH system policies, ICD-10-CM and federal guidelines. 
4. Processes all release of information requests for the LTC facility and logs the request into the Expanse ROI Desktop.
5. Assures the collection, assembly, and filing of  resident charts to assure records are in proper active, overflow and discharge order and stored in a secure area at all times and readily accessible for patient care.
6. Maintains systems for filing, retention and destruction of active, overflow/thinned records and discharge records to prevent loss, destruction and unauthorized use.
7. Contacts physicians as per hospital policy to make them aware of telephone orders, timely physician visits and other documentation that require signatures or dictation by the physicians. 
8. Conducts and maintains routine monitoring of documentation in the LTC medical records to assure compliance with State and Federal regulations.  This monitoring should follow current compliance procedures which may include:   admission/re-admission, concurrent/quarterly, MDS, diagnoses, acute problems and discharge information.  Monthly results are to be calculated and deficiency rates reported to the QA Committee with trending and analysis of issues identified.  Corrective action plans are to be documented and monitored.
9. Assists in the development and implementation of action plans for identified problems/concerns regarding documentation of resident records.
10. Completes and maintains, as applicable, the master patient index information by the facility. 

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Anyone hired after 11/1/2016:   Associates degree, LPN certificate, RHIA or RHIT, preferred.   Prior medical record experience in Long Term Care Facility or hospital Health Information Management (HIM) department required.  Knowledge of ICD-10-CM coding required.  Understanding of medical terminology required; knowledge of regulations, accreditation standards, state minimum standards, and professional standards or practice for health information in long term care preferred; Microsoft Word and Excel skills required.  General office skills including filing, organizing, etc. required.  Good customer service and telephone skills,  Knowledge of documentation and legal issues mandated by HIPAA preferred; Good oral and written communication skills required; Must be able to read, write legibly, speak and comprehend English.  Positive attitude toward the elderly is necessary.

WORKING CONDITIONS

WORK CONTEXT

• Must be able to work independently.
• Requires the ability to withstand pressures of constant deadlines, audits, educational demands and changing healthcare environment.
• Must be able to deal with angry customers, both internally and externally.
• Must be able to communicate both verbally and in writing on a daily basis.
• Must be able to lead and participate in groups. May be required to make presentations to groups on a frequent basis. 
• Must be able to adapt to changes in the work area as assigned.
• Stressful environment working closely with physicians. Frequent high pressure and deadlines to be met.

PHYSICAL FACTORS

• Position is a light work position requiring the ability to exert up to 20 pounds of force occasionally and/or up to 10 pounds of force frequent.
• Prolonged periods of sitting.
• Must be able to kneel, sit, crouch, or stoop with good balance for extended periods of time. . 
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.