Health Information Manager - Alexandria, United States - Bethany on the Lake

Bethany on the Lake Alexandria, United States

3 weeks ago

Description

Bethany on the Lake -

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

About Monarch:

Monarch's mission is to change the way short term rehabilitation and long-term care is delivered. We strive to make patient care and customer service come together, putting the needs of our residents and their families first. We fulfill the communities need for health and housing, in a comfortable well equipped, pleasant home like atmosphere.

We could not provide this caliber of services without our dedicated employees. We value their contributions and work hard to attract and retain the best talent by offering a positive and supportive work environment along with competitive pay, nice perks, and great benefits.

We are an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

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