Health Information Management Coordinator (post-acute)

Boaz Nursing & Rehab Center•Boaz, AL

About The Position

Diversicare Healthcare Services is hiring a Health Information Management Coordinator to oversee patient and resident medical records at a post-acute care center. The role maintains accurate, complete, organized electronic and hybrid clinical records throughout residents’ stays and after discharge or death. It also supports compliance with privacy, security, documentation, and record-retention requirements under applicable state and federal laws. The coordinator audits records, follows up on omissions and discrepancies with relevant staff, supports quality improvement and denials management activities, and provides education to team members on the Electronic Health Record. The position also manages authorized record access and requests, coordinates record storage and destruction, and serves as the center’s representative to the company IT Department for electronic equipment or repair needs.

Requirements

Proficiency in electronic health records and health information systems or applications.
Ability to compile, interpret, and use statistical and clinical data.
Knowledge of legal aspects of documentation and medical terminology.
Knowledge of regulatory and compliance practices for health information under state and federal requirements.
Knowledge of privacy and security regulations relating to confidentiality, access, and release of information.
Basic working knowledge of ICD-10 coding processes and ability to maintain skills as classification-system versions are updated.

Responsibilities

Oversee and audit medical records for new admissions and readmissions, and maintain clinical records throughout each resident’s stay.
Oversee transcription of physician orders for completeness and accuracy.
Communicate with the company IT Department and represent the center regarding electronic equipment and repair needs.
Educate team members on the Electronic Health Record upon hire and as needed.
Participate in the center’s Quality Improvement Program Committee, Clinical Start Up, Daily Business Meetings, Care Management Meeting, and other activities that benefit from record-review findings.
Audit records for omissions and discrepancies; coordinate follow-up with relevant department heads, managers, and licensed nurses; and provide review results to the center Administrator and Quality Improvement Process Committee as needed.
Maintain organized electronic and hybrid clinical records for all patients and residents.
Protect the confidentiality of patient and resident records.
Manage and retrieve patient and resident records and release them only to authorized company personnel.
Review clinical records to verify that the established core data record set contains, at minimum, resident-identifying information, demographic information, diagnosis, treatment, and treatment results.
Maintain separate, organized files for active, thinned, and discharged resident hybrid records.
Within 24 hours of a resident’s discharge or death, or upon return from weekends, holidays, or after-hours, retrieve records; organize hybrid files; review electronic and hybrid records for completeness; route deficiencies to appropriate staff for follow-up; and report deficient findings to the center Administrator.
Address clinical-record requests and submit records to the Corporate Compliance department in a timely manner while maintaining confidentiality.
Oversee record storage and destruction according to record-retention and destruction processes, and maintain a log of destroyed records.
Participate in the center’s Denials Management processes and review records, retrieving supporting documentation as needed.