Nurse Health Information Management Coordinator

Responsibilities

• Closely oversees and audits medical records for new admissions/readmissions and maintains the clinical record throughout the resident’s entire stay within the center.
• Oversees the transcription of physician’s orders for completeness and accuracy.
• Communicates with the company IT Department and is the center representative regarding electronic equipment and/or repair need(s).
• Provides education of team members on the Electronic Health Record upon hire and as needed.
• Active participant in center’s Quality Improvement Program Committee, Clinical Start Up, Daily Business Meetings, Care Management Meeting, and any other area which benefits from the findings of record review activities.
• Audits records for omissions/discrepancies and initiates and participates in follow-up involving the relevant Department Head/Managers, Licensed Nurses and provides review results to center Administrator and Quality Improvement Process Committee for improvement opportunities as necessary.
• Maintains electronic and hybrid clinical records for all patients/residents in an organized manner.
• Upholds the confidentiality of the patient/resident records to protect the sensitive information contained within.
• Manages and retrieves patient/resident records and release to authorized company personnel only.
• Reviews resident clinical records to verify established core data record set contains, at minimum, resident identifiable information, demographic information, diagnosis, treatment, and results of treatment.
• Maintains separate files for active, thinned and discharged resident hybrid records in an organized fashion, for security and ease of retrieval.
• Within 24 hours (or upon return from weekend, holidays or afterhours) of resident discharge or death, retrieves all records; initiates the process of placing hybrid record files in order and reviews electronic and hybrid records for completeness; routes deficient findings to appropriate staff member with follow-up to ensure completeness of records; reports deficient findings to the center Administrator.
• Adds addresses requests for clinical records and submits to the Corporate Compliance department within a timely manner while maintaining records confidentiality.
• Oversight of storage and destruction of records, according to the Record Retention/Destruction processes, and maintains log of destroyed records.
• Participates in the center’s Denials Management processes and is actively involved in records review with retrieval of supporting documentation as necessary.

Qualifications

• LPN or RN strongly preferred
• Proficient in electronic health records and health information systems/applications.
• Ability to compile, interpret and utilize statistical and clinical data.
• Knowledgeable of legal aspects of documentation and medical terminology.
• Knowledgeable of regulatory and compliance practices, specific to state and federal requirements, related to health information.
• Knowledgeable of privacy and security regulations related to confidentiality, access, and release of information practices.
• Basic working knowledge of International Classification of Diseases (ICD-10) coding processes and maintains skills related to future updated classification systems versions.