Health Information Manager

Mountrail County Health Center•Stanley, ND

About The Position

The Health Information Manager codes diagnoses, procedures, and surgeries across patient encounter types and oversees the accuracy, completeness, maintenance, and authorized release of medical records. The role reviews documentation, follows up with providers and nursing staff on corrections, manages record systems and policies, supports quality assurance and risk management, and maintains compliance with privacy requirements. It also includes 340B claim audits, staff training, continuing education, and participation in facility orientation, meetings, and emergency preparedness training. The position requires maintaining confidentiality and treating residents, patients, visitors, and coworkers with kindness, dignity, and respect.

Responsibilities

Code diagnoses, procedures, and surgeries for all patient encounter types using ICD-10-CM, CPT, and HCPCS coding books and an electronic coder.
Review completed records, including lab slips and medications, for accurate and complete documentation, required reports, signatures, and adequate entries.
Confirm diagnoses and consult physicians about potential changes; ensure communication and any resulting changes are adequately documented.
Perform quantitative and qualitative analysis of encounters requiring provider or nurse documentation.
Communicate documentation errors and inefficiencies to providers and nursing staff, and follow up to ensure corrections are made.
Train personnel in record management and maintenance, numbering and file systems, and transcription.
Maintain and annually review the Policy and Procedure Manual, recording changes and filing superseded policies separately.
Establish procedures for collecting data and reviewing records.
Locate and retrieve records requested by authorized staff.
Maintain cooperative relationships with facility staff and employees of other healthcare institutions.
Attend coding workshops, keep coding books current with Coding Clinic and AHIMA changes, and maintain continuing education requirements for RHIT accreditation.
Mail copies of records in response to requests with proper authorization.
Participate in the Quality Assurance program and work with staff to improve quality indicators.
Participate in weekly discharge planning and risk management meetings.
Write, review, and update HIPAA policies and procedures to maintain compliance with the Privacy Rule.
Respond to privacy complaints and investigate HIPAA violations as needed.
Conduct bi-weekly and quarterly audits of 340B claims and document findings.
Communicate documentation requirements to nursing staff and providers.
Perform other assigned duties, which may include HIPAA compliance.
Attend and participate in orientation, training, mandatory education, in-services, staff meetings, and education courses, including Incident Command System training for emergency preparedness.
Maintain resident, patient, staff, and facility confidentiality.
Promote teamwork, encourage others to work to the best of their ability, maintain a positive attitude, accept change and suggestions, follow facility rules and assignments, cooperate with managers and administration, and show respect.
Follow the company dress code.