Health Information Management Manager (HIM)

The Health Information Management (HIM) Manager coordinates all Health Information Management (HIM) functions within the organization including review and analysis of resident medical records, coding diagnoses to the highest level of specificity in accordance with Medicare regulations, oversees the release of medical records, manages electronic , medical records, supports compliance and data quality initiatives, along with ensuring unit secretary functions are completed to compliance standards.

ESSENTIAL JOB FUNCTIONS:

• Encourages and models team approach to accomplish the Luther Manor mission of providing excellent care and services to customers.
• Follows State and Federal regulations as outlined in the Employee Handbook, Nursing Department Policy and Procedure Manuals, Human Resources Manual, and Resident Bill of Rights and adheres to safety rules.
• Reports potential/actual safety hazards to Nurse Manager/Nursing Supervisor and/or Security immediately.
• Coordinates and facilitates the release of medical records a. Screens and verifies that all requests for medical information are in accordance with State/Federal laws and according to organizational and departmental policy.
• Oversees the retrieval of appropriate medical records. Storage of records could be: paper, imaged/electronic, microfilm and others specific to facility.
• Oversees the selection of appropriate documents and the copies of the medical records according to request
• Generates invoices for appropriate requester based on organizational contracts, federal/state guidelines and statutes.
• Determines if a request is valid for certified records according to state statutes, and certifies copies of records that are submitted as evidence in a court of law. Subjected to court orders as deemed necessary by the courts.
• Responds to customers' inquiries and questions as it relates to Release of Information.
• Is cognizant of new regulations/ requirements and complies with State and Federal law regarding all aspects of Health Information Management.
• Uses knowledge regarding HIPAA and state/federal regulations and the impact on release of medical information policies, procedures and processes. Is cognizant of the penalties and ramifications associated with violations of such regulations.
• Assists with establishing, updating, and implementing policies and procedures related to Health Information Management.
• Identifies problems, reports them, and offers suggestions for improvement.
• Uses a variety of technical media and computerized systems.
• Responsible for ensuring compliance with all internal and regulatory standards as they relate to the content and timeliness of medical record documentation.
• Ensure compliance with HIPAA/HITECH for appropriate usage and maintenance of patient confidentiality, appropriate levels of security and control measures to access computer files, information data and for appropriate medical record retention.
• Oversees activities related to the development, implementation, maintenance of and adherence to the organization's policies and procedures covering the privacy of and access to patient health information (PHI).
• Works with organization management, key departments, and committees to ensure the organization has and maintains appropriate privacy and confidentiality, consents, authorization forms, information notices and that materials reflect current organization/legal practices and requirements.
• Analyzes and determines appropriateness of information, including diagnoses for coding, billing, and data entry purposes.
• Works with the Coder to ensure that interpretation, selection, and sequences appropriate ICD According to official coding guidelines and enters information from heavy volume Rehab, LTC and Hospice health records.
• Clarifies inconsistent, ambiguous or non-specific information in a medical record by consulting with the Nurse Manager, Medicare/MDS Coordinator and/or the responsible medical practitioner.
• Interacts frequently with professional staff, Finance and IT departments to resolve coding, software, and documentation issues.
• Shares job knowledge and information with co-workers. Assists with training fill-in, temporary, and new employees in essential job functions as necessary.
• Provides assistance and functions as a key resource in the development, transition and maintenance of Health Record Services.
• Provides assistance and functions as key resource in the continued development of the Health Insurance Portability and Accountability Act (HIPAA).
• Provides expertise on compliance issues and the integration of clinical documentation and coding with the billing process.
• Assists with the development of the health record information systems and processes to meet regulatory requirements and professional practice standards.
• Provides resources on health information, documentation, confidentiality, the release of information and other regulations and standards of practice as they relate to Health Record Services and HIPAA.
• Assists with form development. as needed.
• Provides training and/or in-service education as applicable on health information issues.
• Assists with preparation and provides additional information for denials of insurance coverage, appeals, and requests from legal services.
• Assists Finance and Medicare/MDS Coordinator taking the lead with insurance appeals.
• Adjusts work schedule to meet needs of facility. (ie: workload established by timeframe of admissions.
• Performs coding audits as necessary.
• Participates in department or facility committees as goals and needs require. Supports quality assurance and improvement initiatives of facility.
• Maintains resident/staff confidentiality.
• Fosters and promotes effective relationships with other departments in the facility.
• Attends all Luther Manor mandatory in-services.
• Performs other duties as assigned or as needed.
• Maintains system for filing and retention overflow/thinned records and discharge records.
• Maintains system for storage, retention and destruction of discharge records.
• Develops systems for retention and destruction of health records stored in an electronic format.
• Assists with orientation of new employees on topics such as health record organization and content, record completion, confidentiality, documentation standards and error correction procedures.
• Support and assist with carrying out facility compliance plan, as necessary
• Manage the credentialing process for physicians and other professional staff, when applicable.
• Participate in decisions related to the electronic health record including systems selection, planning and future expansion.
• Provide resources and assist with training on computer system and use of clinical applications.
• Assure ICD code database utilized the current version
• Contact physician or other members of the health care team as appropriate when signatures or information is needed before records can be released and/or completed.
• Assist Unit Nurse Managers with monitoring timeliness of physician visits on a monthly basis.
• Follow up and monitor discharge.

• Health Information Management degree and RHIA or RHIT credential preferred.
• Ability to keep current with Health Information Management changes.
• Knowledge of computer equipment and terminology. Ability to understand data processing concepts. Proficient and accurate on PC, utilizing various software applications.
• Ability to follow and decipher chart documentation.
• Ability to understand and interpret computer reports.
• Good manual and finger dexterity.
• Ability to perform repetitious keyboarding for extended periods.
• Ability to enter data rapidly and within acceptable levels of accuracy.
• Ability to work under pressure in a fast-paced environment with time constraints.
• Ability to prioritize workload and maximize time utilization.
• Excellent written and oral communication and grammar skills. Ability to communicate appropriately with professional staff and co-workers. The ability to read, speak and write English.
• Strong organizational skills. Ability to prioritize, organize, and meet deadlines.
• Ability to handle multiple priorities in stressful situations.
• Ability to work with minimal supervision.
• Must have the ability to spend 95% of the work shift stationary and utilizing computer.
• Must be able to push, pull or lift up to 25 lb.
• Must follow Administrative Dress Code.
• Ability to understand state and federal regulations and statutes.

Supervision:

• Reports to Director of Nursing Services
• Supervises Unit Secretaries, and Medical Records Specialist.