Health Information Manager
POSITION SUMMARY
The Health Information Manager (HIM) is responsible for maintaining the integrity of the health information system and medical records for every resident, ensuring they are accurate, systematically organized, complete and readily accessible. The HIM is responsible for the oversight of confidentiality, compliance, privacy and security of the health information system and its contents. Instances where there is only one HI staff, the HIM will complete all necessary HI duties.
ESSENTIAL RESPONSIBILITIES AND DUTIES
HEALTH INFORMATION MANAGEMENT
- Maintains security of health information system and medical records through ensuring: physical protection to prevent loss, destruction and unauthorized use; facility safeguards are in place such as record sign-out systems, assignment of computer passwords/logins; systems are in place for securing file cabinets and file rooms where overflow and discharge records are stored; systems are in place to maintain confidentiality/privacy of both manual and electronic health information.
- Manage the release of health information including review and processing of all information requests.
- Maintains systems for filing, retention and destruction of overflow/thinned records and discharge records that are compliant with state, federal and HIPAA guidelines.
- Follows MHM system for retention and destruction of medical records stored in electronic format.
- Maintains daily census, tracking admissions, discharges, case mix changes, LOA, Medicare, hospitalizations, room changes and changes in pay status.
- Communicates census changes, case mix to appropriate MHM staff using designated methods and forms.
- Ensures auditing trails are in place and are monitored closely.
- Ensures disease database utilizes the current version of ICD.
- Ensures systems are in place to continually maintain resident information in the information system.
RECORDS MANAGEMENT
Admission
- Ensures admission process is comprehensive and resident-centered.
- Completes and files: appropriate information in the census register; master patient index information; admission checklists and admission audits; coding and indexing of admission diagnoses.
- Initiates the inpatient medical record and in-house overflow file, prepares labels, etc. During Resident’s Stay.
- Conduct audits and quality monitoring at regular scheduled intervals.
- Code diagnoses at regular scheduled intervals.
- Thin in-house records in accordance with the written policy/procedure and file in chart order for discharge in in-house overflow file.
- Contact physicians or departments as needed for needed signatures.
- Maintain a trending and evaluation system that identifies that telephone orders and other information is completed and signed by physician timely.
- File all incoming clinical information in the in-house records daily; scanning for electronic records.
- Monitor timeliness of physician visits to ensure compliance with federal and state regulations; report physicians who are out of compliance to Administrator and DON.
Discharge
- Update discharge information on the master patient index.
- Record appropriate discharge information in the census register.
- Initiate the discharge record control log to monitor discharge records processing status.
- Obtain discharge clinical record from the nursing station within 24 hours of discharge or death of resident.
- Assemble record from the nursing station and the overflow file in established discharge order.
- Analyze the record for deficiencies using the discharge record audit/checklist.
- Follow up and monitor discharge record deficiencies including monitoring mail information to physician for completion as applicable.
- Maintain discharge record control log.
- File discharge record in incomplete clinical record file until completed, then in complete file.
- Code and index final diagnoses using the current version of the ICD.
SUPERVISION AND MANAGEMENT
- Depending on number of residents, resident acuity and complexity, may supervise 1 – 2 Health Information Assistants.
- Discusses issues and solutions affecting Health Information department with department directors.
- Works with Administrator to ensure adherence to HIPAA privacy policies and the protection of residents rights concerning their identifiable health care information.
- Supports and engages in QAPI initiatives; completes quarterly resident roster.
- Ability and willingness to work some evenings and weekends as directed by supervisor.
QUALIFICATIONS
Education and Experience
- High School graduate or equivalent.
- Knowledge of medical terminology.
- Long-term care or healthcare experience.
Preferred
- Registered Health Information Technician or knowledge of professional standards of practice for Health Information field in long-term care.
- Previous experience as a HI Assistant or HUC; training in medical records; experience with coding.
- Knowledge of regulations, survey process, documentation requirements and legal issues.
- Understanding of payment systems including Medicare and Medicaid.
Required Skills and Abilities
- Empathy for elderly with ability to be sensitive to resident and family needs.
- Resilience; ability to provide/receive constructive feedback, course correct and not take it personally.
- Motivator; ability to ensure staff feel supported while ensuring accountability to work expectations.
- Personability; ability to get along with all personality types and inspire trust with residents, staff, family and the community.
- High emotional intelligence (EQ).
- Ability to actively listen, with the goal of understanding.
- Ability to clearly speak and proficiently read and write in English.
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