Health Information Manager

National Health- White Oak Group•Lancaster, SC

1d•Onsite

About The Position

Under the guidance of the Health Information Management Consultant, the Health Information Manager is responsible for maintaining the policies and procedures established for the record-keeping practices of the center in accordance with HIPAA requirements. This role involves managing patient admissions, ensuring the completeness and accuracy of medical records, analyzing records upon patient dismissal, compiling statistics, controlling and preserving records, and handling correspondence and medicolegal aspects of records. The position also includes leadership and supervisory duties, professional interaction with healthcare professionals, and the ability to establish procedures and suggest operational improvements.

Requirements

High school diploma.
Must successfully complete the 90-day evaluation period.
Ability to effectively communicate with Administrators, Physicians, Health Care Professionals and Corporate Support Staff.
Ability to establish procedures and to suggest changes for smoother operations.
Data entry skills and the ability to effectively type.
Understanding of medical record systems including but not limited to filing systems, EMR functions, medical terminology, ICD-10-CM coding principals, concurrent and discharge analysis.
Personal attributes include professionalism, neatness, detail oriented, accuracy, ability to articulate pleasantly, and cooperative with all staff.

Nice To Haves

Preferred knowledge of ICD-10-CM coding guidelines.
Preferred minimum of 3-5 years in a medical office or LTC setting with familiarity of medical terminology.
Preferred minimum of 3-5 years of experience in the field of health information, preferably in a long-term care setting.

Responsibilities

Maintain policies and procedures for record-keeping practices per HIPAA requirements.
Adhere to HIPAA MINIMUM NECESSARY guidelines and safeguard protected health information.
Admit patients: Code admission diagnosis according to ICD-10-CM coding guidelines and principles and enter codes in the EMR system in a timely manner.
Conduct admission chart audits to ensure completeness of the admission record.
Determine if additional transfer data is needed and request from the transferring facility.
Perform specific duties on in-house medical records: Check the record on admission and periodically (not less than monthly) to assure completeness, accuracy, and internal consistency.
Report on any trends to the Quality Assurance Performance Improvement Committee.
Communicate with and assist medical staff and allied health personnel in updating records.
Maintain the flow of documentation to the records.
Update diagnostic list as changes occur by coding additional diagnoses documented by providers and resolving inactive diagnoses.
Review diagnostic list for accuracy in conjunction with the MDS schedule.
Maintain a tracking system for timely physician visits and certifications.
Analyze and evaluate medical records upon dismissal of the patient: Check discharge documentation quantitively in accordance with the discharge chart audit to assure completeness, accuracy, and internal consistency.
Obtain complete and accurate records within thirty (30) days or in accordance with state regulations (whichever is less).
Code final and/or death diagnoses according to ICD-10-CM and assure the face sheet discharge information is correct and consistent throughout the chart.
Ensure all required reports are in the record.
Follow appropriate procedures for closing a medical record permanently incomplete, if required.
Collect, correlate, and maintain statistical data as needed.
Report monthly audit findings to the Corporate Consultants as directed.
Provide information, when requested, to those involved in research projects and studies with the approval of the home office and the Administrator.
Assist the medical staff by providing data from the medical records for Quality Assurance Performance Improvement and various audits.
Maintain the numerical filing system for records (if applicable).
Maintain the unit numbering system for record identification (if applicable).
Maintain the necessary sign-out and follow-up controls of records.
Analyze admission, transfer, and discharge records for deficiencies and follow up on incomplete records with designated staff until resolved.
Maintain a master form book and full inventory supply of all forms for chart use.
Maintain and control the release of information to authorized persons.
Notify appropriate corporate staff of release of information requests prior to release.
Maintain and control disclosure log of all information releases.
Maintain confidentiality, security, and physical safety of health information and medical records.
Attend all mandatory meetings, as well as any other specific meetings as designated by the center administrator and DON.
Assist Staff Development Coordinator with nursing orientation for documentation guidelines as needed.
Assist as preceptors to local students of a HIT/HIA program (for credentialed partners).
Maintain professional interaction with all Health Care Professionals, Physicians, Administrators, and Corporate Support Staff.
Perform all functions and aspects of the Health Information Department as necessary.
Effectively communicate with Administrators, Physicians, Health Care Professionals and Corporate Support Staff.
Establish procedures and suggest changes for smoother operations.
Proficiently respond and manage the release of health information functions for the facility including the processing and tracking of all requests for medical records information.