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Westborough Behavioral Healthcare Hospital Director of Health Information-Medical Records Director in Westborough, Massachusetts

Westborough Behavioral Healthcare Hospital (WBHH) provides psychiatric stabilization treatments for Children, Special Needs and Adult populations in inpatient settings. Our goal is to ensure patients and their loved ones feel comfortable and are well informed regarding treatment options.

The Director of Health Information is responsible for directing the activities of the Health Information Management Services Department in the management and maintenance of all patient medical records information, ensuring compliance will all state and federal laws, rules/regulations of licensing agencies and within Joint Commission standards for the quality of patient care.

Essential Duties:

· Direct the Health Information Management Service Department within all standards established by regulatory and licensing agencies.

· Consult with the Hospital Administration and medical staff to ensure that all patient records are maintained within standards established by appropriate licensing agencies.

· Maintain confidentiality of medical records. Ensure the release of files and/or records to appropriate and authorized authorities. Adherence and compliance with al HIPAA standards and regulatory requirements

· Supervise and engage department colleagues to ensure effective organization and completion of assignments.

· Ensure effective departmental staffing.

· Monitor the accuracy and appropriate maintenance of medical records on every patient, ensuing compliance with rules and regulations of state agencies, Joint Commission on Accreditation of Health Organizations, and Medical Staff Bylaws.

· Respond to inter-departmental and external inquiries and questions. Oversees all subpoenas and other legal requests pertaining to medical records. Monitor the coding of all discharged patient charts, and abstract all pertinent patient information for forwarding to state agencies, as required.

· Coordinate the preparation and/or revisions to medical record, forms, ensuring compliance with all requirements of JCAHO, applicable state and federal laws, Bylaws and Rules/Regulations. Prepare as requested statistical reports for administration.


· Participate in, or lead various management and/or committee meetings as assigned. Assist in the abstraction and analysis of data from the medical record for medical care evaluation studies, patterns of patient care and Performance Improvement. Monitor the quality of the transcription services offered by the department, to ensure accuracy and timeliness.

· Remain current and up to date on all laws regarding Health Information Management.

· Ensure the continuous professional development of self and staff, by attending professional meetings, seminars, and training.

· Meet the requirements of the American Health Information Management Association in assuring not only active accreditation but a means of keeping abreast in the ever-changing field of Health Information Management Services.

· Adhere to facility, department, corporate, personnel, and standard policies and procedures.

· Attend all mandatory facility in-services and staff development activities as scheduled.

· Adhere to facility standards concerning conduct, dress, attendance and punctuality.

· Support facility-wide quality/performance improvement goals and objectives.

· Maintain confidentiality of facility employees and patient information.


Education and/or Licensure – High School Diploma or equivalent required, College degree preferred.

Experience – Experience in a psychiatric setting required; familiarity with psychiatric terminology and treatment modalities; organizational skills; analytical evaluative, interpretive, and problem-solving skills; basic supervisory skills and fiscal management skills. Ability to maintain information as highly confidential; knowledge of and skills interpreting and applying laws, standards, and regulations affecting health information systems, specifically in mental health service areas.

Licensure: RHIA Required.


Eligible employees receive a generous benefits package including holiday premium pay, shift differentials, health, dental and vision coverage, 401(K) plan, health & dependent Flexible Spending accounts, generous paid time off, company paid life, short-term and long-term disability coverage, and an employee referral bonus plan.