Health Information Manager

Essential Duties and Responsibilities:

1. Codes diagnoses, procedures, and surgeries on all patient encounter types using the ICD-10-CM, CPT, and HCPCS coding books and electronic coder.
2. Checks completed records, including lab slips and medications, for accurate and thorough documentation by providers and nursing staff to ensure that all reports are in the record and all entries are properly signed and adequately documented.
3. Confirms the listing of diagnoses and checks with the physician if there are changes to be considered. If changes are required, ensure adequate documentation of communication with provider and accurate documentation of changes in the record.
4. Perform quantitative and qualitative analysis on all encounters that require provider or nurse documentation. Communicate with providers and nursing staff regarding errors and inefficiencies that need to be corrected. Follow up to ensure appropriate changes have been made.
5. Trains personnel responsible in the techniques of record management and maintenance, numbering and file systems, and transcription.
6. Maintains an up-to-date Policy and Procedure Manual with all changes recorded and old policies filed in a separate folder. Reviews manual on an annual basis.
7. Establishes procedures for data collection and review of records.
8. Locate and retrieve records requested by authorized staff.
9. Maintains helpful and cooperative relationships with staff and other employees in the facility and staff and employees of other healthcare institutions.
10. Attends coding workshops and keeps coding books current on changes made by Coding Clinic and AHIMA.
11. Maintains continuing education requirements for RHIT accreditation.
12. Mails copies of records for which there is a request with proper authorization.
13. Participate in Quality Assurance program and work with necessary staff to ensure improvement in quality indicators.
14. Participate in weekly discharge planning and risk management meetings.
15. Write, review and update HIPPA policies and procedures to remain compliant with the Privacy Rule. Respond to privacy complaints. Conduct investigations into HIPPA violations as needed.
16. 340B Program
17. Perform Bi-weekly and Quarterly Audits on 340B Claims & Document Findings
18. Communicate with nursing and providers on documentation requirement.
19. All other duties as assigned, which may include HIPAA Compliance, etc.
20. Attend and participate in orientation, training, mandatory education, in-services, staff meetings and education courses to further improve knowledge and skills, including Incident Command System training (ICS) for emergency preparedness.
21. Maintain Resident, Patient, Staff and Facility Confidentiality.
22. Treat Residents, Patients, Visitors and Co-workers with kindness, dignity and respect at all times.
23. Promote teamwork; encourage others to work to the best of their ability.
24. Have a positive attitude; accept change willingly; follow facility rules, regulations and job assignments; accept suggestions well for work improvement; cooperate with other managers and administration and show respect at all times; speak well of company and job.
25. Follow company dress code.