Health Information Management Coordinator/Medical Records Nurse

Diversicare•Montgomery, AL

21d

About The Position

At Diversicare, we're more than just a company – we're a passionate community dedicated to caregiving excellence. If you're driven by a desire to make a difference in the lives of patients and residents, then we invite you to be part of our extraordinary team. Why Choose Diversicare: We're Proudly Agency-Free: Unlike other companies, we believe in building a direct connection with our team members, fostering trust, respect, and collaboration. Compassion-Driven Culture: At Diversicare, we value trust, respect, customer focus, compassion, diplomacy, appreciation, and strong communication skills. We're committed to creating a warm, caring, safe, and professional environment for both our customers and our team. Competitive Benefits: We offer a comprehensive benefits package that includes medical/dental/vision coverage, an excellent 401k plan, tuition reimbursement, vacation, holiday, and sick time, long and short-term disability, and much more. Room for Growth: Join a dynamic environment where you can grow in your career and make a lasting impact on the healthcare industry. Meaningful Mission: Our mission is to "Improve every life we touch by providing exceptional healthcare and exceeding expectations." A mission we truly live and breathe. Core Values: We are guided by five core values - Integrity, Excellence, Compassion, Teamwork, and Stewardship, as well as 12 Service Standards.

Requirements

Proficient in electronic health records and health information systems/applications.
Ability to compile, interpret and utilize statistical and clinical data.
Knowledgeable of legal aspects of documentation and medical terminology.
Knowledgeable of regulatory and compliance practices, specific to state and federal requirements, related to health information.
Knowledgeable of privacy and security regulations related to confidentiality, access, and release of information practices.
Basic working knowledge of International Classification of Diseases (ICD-10) coding processes and maintains skills related to future updated classification systems versions.

Responsibilities

Closely oversees and audits medical records for new admissions/readmissions and maintains the clinical record throughout the resident’s entire stay within the center.
Oversees the transcription of physician’s orders for completeness and accuracy
Communicates with the company IT Department and is the center representative regarding electronic equipment and/or repair need(s).
Provides education of team members on the Electronic Health Record upon hire and as needed.
Active participant in center’s Quality Improvement Program Committee, Clinical Start Up, Daily Business Meetings, Care Management Meeting, and any other area which benefits from the findings of record review activities
Audits records for omissions/discrepancies and initiates and participates in follow-up involving the relevant Department Head/Managers, Licensed Nurses and provides review results to center Administrator and Quality Improvement Process Committee for improvement opportunities as necessary
Maintains electronic and hybrid clinical records for all patients/residents in an organized manner.
Upholds the confidentiality of the patient/resident records to protect the sensitive information contained within.
Managing and retrieving patient/resident records and release to authorized company personnel only.
Reviews resident clinical records to verify established core data record set contains, at minimum, resident identifiable information, demographic information, diagnosis, treatment, and results of treatment.
Maintains separate files for active, thinned and discharged resident hybrid records in an organized fashion, for security and ease of retrieval.
Within 24 hours (or upon return from weekend, holidays or afterhours) of resident discharge or death, retrieves all records; initiates the process of placing hybrid record files in order and reviews electronic and hybrid records for completeness; routes deficient findings to appropriate staff member with follow-up to ensure completeness of records; reports deficient findings to the center Administrator.
Addresses requests for clinical records and submits to the Corporate Compliance department within a timely manner while maintaining records confidentiality.
Oversight of storage and destruction of records, according to the Record Retention/Destruction processes, and maintains log of destroyed records.
Participates in the center’s Denials Management processes and is actively involved in records review with retrieval of supporting documentation as necessary.