Director of Medical Records

Job Description

Lincoln Medical and Mental Health Center is one of New York City’s premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women’s Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Work Shift:

9:00 A.M – 5:00 P.M

PURPOSE OF POSITION:

Under direction, administers the development and management of the medical records programs, including the design, planning, coordination, and implementation of systems, programs, practices, methods, and procedures, to achieve effective medical record administration and operations. Ensures compliance with applicable laws and regulations; oversees the maintenance of both electronic and paper-based records; manages staff; and develops policies and procedures to optimize record management.

In addition, and with reference to the corporate Director of Medical Records Services job specification incorporated by reference below, directs the coding, clinical documentation integrity, record completion, data integrity, and release-of-information functions within the incumbent's assigned scope; establishes recurring performance reporting, revenue-cycle accountability, and escalation practices for all areas of assigned responsibility; and ensures accreditation and regulatory readiness, without regard to the specific facility or organizational unit assigned.

DUTIES AND RESPONSIBILITIES:

Duties 1 through 14 are reproduced from the corporate job specification. Duties 15 through 28 state the standing responsibilities of the position as applied at the facility level.

1. Engages in planning for and evaluation of administrative systems employed in the maintenance and utilization of medical records across the Corporation. Stays current with advancements in medical record technology and best practices.

2. Supervises departmental operations to ensure efficiency and is responsible for hiring and training programs to meet the needs of all medical record department staff.

3. Develops and maintains a record retention and destruction schedule.

4. Directs studies in order to furnish technical information and management analysis involving the pinpointing of problem areas and alternate policy positions.

5. Supervises the development and installation of major automated systems and approves methods and procedures, systems and controls to improve the quality and timeliness of medical record administration and operations.

6. Directs data processing feasibility studies relevant to medical record administration applications, including design of applications in multi-faceted areas.

7. Reviews and advises senior leadership and local administrations on operational and capital expenditures of medical record administration.

8. Anticipates accreditation problems in functional areas of medical records and makes recommendations to remedy the situation(s).

9. Initiates studies and design of systems to provide information for efficient patient care and retrieval of management information for reporting, planning and decision-making purposes.

10. Establishes performance standards and policy outlines for the administration of medical record departments, including such factors as personnel, chart handling, as well as the management of electronic and paper records such as coding, indexing record summaries, filing, and retrieval.

11. Leads committee(s) in the evaluation, planning and coordination of the effective delivery and maintenance of complete, accurate medical records services in full compliance with all pertinent laws, rules, and regulations. Ensures adherence to standards set by The Joint Commission, Centers for Medicare & Medicaid Services, New York State Department of Health, New York State Office of Mental Health, the Health Insurance Portability and Accountability Act (HIPAA), and other regulatory agencies.

12. Supervises medical records staff and provides direction, guidance, and performance evaluation; conducts audits of programs, makes recommendations and takes appropriate action in alignment with corporate policies and practices.

13. Manages all requests for medical records and ensures it is shared with authorized individuals or organizations.

14. Maintains liaison with professional groups in areas of data automation, medical records, systems and health care setting administration, and liaison with governmental agencies for purpose of grant-in-aid possibilities, and information required for systems analysis applications to health policy questions.

15. Inpatient, outpatient, and emergency coding operations. Directs the inpatient, ambulatory-surgery, emergency, and outpatient coding functions within the incumbent's assigned scope, establishing productivity, accuracy, and turnaround standards consistent with recognized industry benchmarks, and monitoring coding capacity against volume and case-mix.

16. Clinical documentation integrity (CDI). Directs the inpatient and outpatient clinical-documentation-integrity program, including query rate, physician response and agreement rates, review coverage as a percentage of eligible encounters, and documentation-driven case-mix and risk-capture performance, in coordination with medical staff and physician advisors.

17. DRG validation and coding quality. Directs DRG validation and coding-quality review, including validator-to-coder ratios, audit sampling and overturn rates, DRG downgrade rates, and CC/MCC capture, and maintains bench depth sufficient to avoid single points of failure in any coding or validation function.

18. Revenue-cycle performance and reporting. Owns the health-information contributions to revenue-cycle performance, including discharged-not-final-billed (DNFB) days, discharge-to-coding turnaround, coding backlog volume and aging, and coding-related denial rate; reports these on a defined cadence with values reconciled to the health care system's cash-basis reporting of record and to the applicable revenue-cycle performance standards.

19. Record completion and chart integrity. Directs chart-completion and delinquency management against medical-staff bylaws and Joint Commission standards, and directs data-integrity operations including duplicate medical-record-number rate and master-patient-index quality.

20. Assembly, scanning, and quality assurance. Directs assembly, scanning, indexing, and quality-assurance operations, establishing scan-to-record timeliness and completeness standards and distinguishing sampling design from backlog in any quality-assurance gap.

21. Release of information. Directs the release-of-information function, whether performed in-house or through a contracted vendor, ensuring turnaround within HIPAA and applicable State timeframes, service-level standards for external requests, and vendor quality validation.

22. Registries and accreditation-required data. Ensures the maintenance and adequate staffing of registries and accreditation-required data functions applicable to the facility, consistent with the standards of the relevant accrediting bodies, and escalates any staffing ratio or resourcing gap that places accreditation at risk.

23. Recurring performance reporting. Establishes and maintains a system of recurring written performance reporting to executive leadership covering every function within the incumbent's assigned scope, on a defined cadence, with current status, trends, blockers, and items requiring executive involvement.

24. Escalation of material matters. Identifies and escalates to executive leadership, in writing and at the time identified, any material adverse trend, compliance exposure, accreditation risk, or resourcing gap affecting an assigned function, together with quantified impact where determinable and a proposed corrective plan. Where an escalation does not produce resolution, adapts the method of engagement and convenes the responsible parties directly.

25. Identification, tracking, and coordination of performance matters. Identifies material performance problems affecting the functions within the incumbent's assigned scope, tracks them to resolution, convenes and coordinates the clinical services, departments, and resources required to address them, and reports current status and next actions to executive leadership. Where the remedy sits with a clinical service or another department, the incumbent remains responsible for convening that party, coordinating the work, and reporting the status.

26. Clinical engagement. Establishes and maintains direct working engagement with the clinical chiefs and medical staff of the services generating the department's documentation, coding, and delinquency exposure, at a defined cadence and in a format suited to clinical schedules.

27. Written procedures, performance standards, continuity, and delegation. Establishes performance standards, written procedures, and desk-level documentation for the functions within the incumbent's assigned scope, and maintains them as current operating references. Establishes and maintains a coverage and delegation structure, including designated alternates for critical single-incumbent functions and a defined escalation path, ensuring continuity of operations and reporting during any period of the incumbent's unavailability, and escalates structural or staffing constraints to executive leadership.

28. Performs other related duties, as required.

Minimum Qualifications:

1. Master’s Degree from an accredited college or university in Business Administration, Management, Health Administration or Information Management, Industrial Engineering, Medical Records Library Science, or a related discipline; and five (5) years of satisfactory experience in business, government, a hospital, or related health care organization in medical records services and systems, of which at least two (2) years must have been in a managerial, administrative and/or supervisory capacity; or

2. Bachelor’s Degree from an accredited college or university in Business Administration, Management, Health Administration or Information Management, Industrial Engineering, Medical Records Library Science, or a related discipline; and six (6) years of satisfactory experience in business, government, a hospital, or related health care organization in medical records services and systems, of which at least two (2) years must have been in a managerial, administrative and/or supervisory capacity.

3. All candidates must maintain a Registered Health Information Administrator (RHIA) credential from the American Health Information Management Association (AHIMA) or a Registered Health Information Technician (RHIT) credential from AHIMA.

Departmental Preferences:

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• Knowledge of health information management, inpatient and outpatient coding, clinical documentation integrity, DRG validation and coding quality, chart completion and delinquency management under medical-staff bylaws and Joint Commission standards, release of information under HIPAA and applicable State law, data integrity and master-patient-index quality, registries and accreditation-required data, and the health-information contributions to revenue-cycle performance.
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• Ability to convene and coordinate clinical services and other departments; ability to translate coding and documentation data into actionable reporting for clinical and executive leadership; strong written and verbal communication; ability to partner effectively with clinical chiefs, medical staff, physician advisors, department heads, and Central Office.
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