Health Information Manager

PURPOSE:

Under guidance of the Health Information Management Consultant, the Health Information Manager maintains the policies and procedures established for the record-keeping practices of the center per HIPAA requirements.

EDUCATION AND

QUALIFICATIONS:

High school diploma. 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. Employment with exceptions to the above qualifications is subject to discretion from the Administrator with guidance from the Corporate Health Information Consultant.

Must successfully complete the 90-day evaluation period.

WORKING HOURS:

Works 80 hours every two weeks (usually 8:30 a.m. until 5:00 p.m.)THIS PERSON

REPORTS TO:

Director of NursingHIPAA MINIMUM NECESSARY:

Responsible to adhere to HIPAA MINIMUM NECESSARY guidelines and safeguard protected health information.

WORKING CONDITIONS:

Well-lighted and ventilated office and/or nursing neighborhoods. Subject to frequent interruptions.

DUTIES:
1. Admission of patients:
Code admission diagnosis according to ICD-10-CM coding guidelines and principles and enter the codes in the EMR system in a timely manner. Conduct admission chart audits to ensure the completeness of the admission record. Determine whether additional transfer data is needed and request from transferring facility. Follow up to ensure receipt.

Perform specific duties on in-house medical records (or delegate if appropriate):
Check the record on admission and then 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 the medical staff and allied health personnel in updating the records. Maintain the flow of documentation to the records. Update diagnostic list as changes occur by coding additional diagnosis documented by the providers and resolving inactive diagnosis.

Review diagnostic list for accuracy in conjunction with the MDS schedule. Maintain a tracking system for timely physician visits and certifications.

Analysis and evaluation of 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 the regulations of your state (whichever is less). Code final and/or death diagnosis 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.

Compilation of statistics and special reports:
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.

Control and preservation of the records:
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. Maintains a master form book and full inventory supply of all forms for chart use.

Correspondence and medicolegal aspects of the records:
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…