Health Information Director – SNSVH

Incumbents at this level organize, coordinate and administer a comprehensive health information system which includes multi-disciplinary medical/clinical records for an acute care facility, inpatient facility, correctional facility, skilled nursing facility, or facility for individuals with intellectual or developmental disabilities and outpatient services. 

Incumbents at this level formulate, develop and implement policies and procedures related to the handling, dissemination, confidentiality and preservation of health information; provide technical expertise to treatment and other facility personnel concerning facility, legal and regulatory requirements related to the control, use and release of health information; oversee records quality assurance activities; supervise clerical support and medical records personnel involved in transcription, scanning, coding, indexing, chart analysis, release of information, storage and retrieval functions; and perform medical records duties as required.

Serve as liaison between the facility and survey teams from regulatory agencies and accrediting bodies by providing requested information and ease-of-access to medical records. 

Prepare reports by researching various sources, ascertaining accuracy of information, compiling statistics, and summarizing findings in order to display health care data for administration, medical staff, and licensing, regulatory and accrediting agencies. 

Participate in facility committees which develop, interpret and disseminate health information policies and procedures including determining the content of medical records, developing new forms, quality improvement activities, and other projects as assigned. 

Prepare and maintain medical/clinical records according to facility standards and accepted filing methods and procedures; create new records; file documents in appropriate sections; thin and purge records according to established facility policies and procedures; archive records of patients no longer receiving services; provide technical assistance and training to facility staff regarding records maintenance practices. 

Participate in quality improvement activities such as auditing records; verify completeness, flag deficiencies, notify appropriate personnel regarding deficiencies, and follow up until record is complete and properly documented; compile data, statistical reports and results of quality improvement audits as required. 

Request and enter health information received from external sources including hospitals, clinics, physicians, laboratories and other providers to maintain complete and accurate medical records. 

Maintain record and patient confidentiality in accordance with rights to privacy and related laws and regulations; control access to records and authorize release of information according to legal, facility and regulatory requirements; release information upon receipt of properly executed consent agreements or court orders; and protect patient identity when preparing reports for legal, licensing, or certifying agencies. 

Prepare and maintain summaries, indexes and registers related to medical/clinical records to ensure efficient access and retrieval of data. 

Perform administrative support duties related to medical office activities such as scheduling appointments and transcribing information as needed. 

Perform related duties as assigned.