Health Information Specialist

Overview

The Health Information Specialist is responsible for the management of the Care Center Resident Health Information system which includes organization and management of Resident medical records, management of requests for information, support with and maintenance of the electronic health record (EMR), coordinating passcodes and access to Point Click Care (PCC) clinical and interdisciplinary Care Center Team and assistance with Care Center Team Members education to include the electronic education program.

The Care Center is defined as the skilled nursing facility (SNF) and the assisted living facility (ALF) at the Nebraska campus. The SNF has 80 licensed beds and the ALF has 65 apartments licensed for a maximum of 88 Residents. This position includes being knowledgeable of all SNF Federal and State rules and regulations of SNFs and ALF State regulations as well as standards of professional practice. Blood and body fluids exposure: Category III.

RESPONSIBILITIES: Include the following. Other duties may be assigned.

• Keeps confidential all information not specifically authorized to be given to others.
• Support the activities of the clinical services Team Members
• Admission of Residents
• Assure that the Resident is properly registered in the necessary indices of the center (i.e., Resident Number Register and Master Resident index).
• Code admission diagnoses according to the current coding guidelines and principles and enter the codes into appropriate system(s).
• Assure that Admission Summary Sheet is complete.
• Determine whether additional transfer data is needed and request from transferring facility if necessary. Follow up to assure receipt.

• Perform specific duties on in-house health records (or delegate as appropriate):
• Check the record quantitatively on admission and periodically to assure completeness, accuracy and internal consistency. Report trends to the quality assurance performance improvement committee.
• Communicate with and assist the medical staff and allied health personnel in updating records.
• Maintain the flow of the reports to the records.
• Update diagnostic lists as changes occur by coding additional diagnoses documented by physician and resolving inactive diagnoses. Review diagnostic lists for accuracy in conjunction with the MDS schedule and sign for accuracy of MDS Section I.
• Complete timely certifications and recertification on Medicare Residents.
• Create outside Rehab Company postage invoicing.
• Analysis and evaluation of health records upon dismissal of Resident:
• Check the discharge documentation quantitatively to assure completeness, accuracy, and internal consistency.
• Obtain complete and accurate records within thirty (30) days.
• Assure Admission Summary Sheet discharge information is correct.
• Assure all required reports are in the record.
• Follow appropriate procedures for closing a record permanently incomplete, if required.
• Maintain secondary records systems:
• Maintain the Resident Number Register
• Verify the accuracy of the Master Resident Index upon admission and discharge of the Resident.
• Maintain overflow records.
• Maintain a tracking system for physician visits and the authentication of orders.
• Maintain accurate and timely Medicare certifications.
• Compilation of statistics and special reports:
• Collect, correlate, and maintain statistical data as needed.
• Provide information, when requested, to those involved in research projects and studies with approval of center owner and administrator.
• Assist the medical staff by providing data from the health records for Utilization Review, Pre-Billing, quality assurance performance improvement committee and various audits.
• Control and preservation of records:
• Maintain the numerical filing system for records.
• Maintain the unit numbering system for record identification.
• Maintain the necessary sign-out and follow-up controls of records.
• Maintain drug control count sheets for two years in a separate file form the medical record if there is no in-house pharmacy.
• Correspondence and medico-legal aspects of records:
• Maintain and control release of information to authorized persons.
• Type and/or transcribe reports or correspondence according to the needs of the HIM Department.
• Department Head/Supervisory Duties:
• Attendance of all Department head meetings. In addition, may be required to attend Pre-Billing and quality assurance performance improvement committee, as well as other specific meetings as designated by the administrator.
• Orientation of new partners to the HIM Department and orientation of nursing and other ancillary partners involved in the documentation process. This orientation will involve both State and Federal regulations and center policies and procedures, as well as documentation recovery education.
• Interaction with all health care professionals, physicians, administrators, and consultant support staff.
• Pull monthly electronic education attendance roster and reconcile with and add to individual Team Member logs.
• Maintain and update individual education records of Team Members as a back up to the Care Center Quality Assurance Manager.
• Run monthly educational deficient reports for Care Center Administrator.
• Complete Time Punch Exception slips for hours worked outside of scheduled work hours. May use company mobile device or personal mobile device for needed access as requested.
• Observes and follows safety policies and procedures.
• Observes and follows infection control policies and procedures.
• Attends all mandatory inservices as required.
• Demonstrates positive guest relations to internal and external customers.
• Team Members are required to report to their Department Director all incidents of actual or possible abuse of a Resident that they become aware of. Abuse in this respect includes, but is not limited to, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, neglect, and/or any misappropriation of property concerning St. Mark Village Residents. Team Members will make the report as soon as possible after they become aware of the incident of actual or possible abuse.
• May be assigned other related duties and responsibilities as required by the Care Center Administrator.
  

Supervisory Responsibilities

This job has no supervisory responsibilities.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must be courteous, considerate and understanding when dealing with Residents, Team Members, and visitors. Ability to work in close cooperation with others.

Required Skills, Education And/Or Experience

• Must be a registered health information technologist (RHIT) or trained medical record professional.
• Associate’s degree (A.A.) or equivalent from two-year college or technical school; minimum one to three years related experience and/or training; or equivalent combination of education and experience.
• Proficient in Microsoft Office, including knowledge of Word, Excel, Outlook required.
• Must demonstrate excellent communication skills both verbally and electronically. Must Possess thorough organizational skills, as well as an ability to work well with a Team.
• Must demonstrate experience in Proficient Data Entry and Reporting, or equivalent combination of education and experience.
  
  

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of Residents or Team Members of facility. Ability to maintain verbal and written communication with co-workers and business associates outside the community.

Mathematical Skills

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Certificates, Licenses, Registrations

Must be a registered health information technologist (RHIT) or trained medical record professional.

Physical Requirements

The physical demands described here are representative of those that must be met by a Team Member to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Must be able to unrestricted sit, stand, bend, reach, stoop, walk, and move intermittently during working hours. The Team Member must occasionally lift and/or move up to 35 pounds. Adequate vision to supervise care delivery. Alert and attentive to detail. Ability to remember locations names, and people. Analytically competent. Basic data entry skills and the ability to type. Understanding of health records systems, including filing systems, medical terminology, current coding principles, concurrent and discharge analysis procedures, medico-legal aspects and possess management skills for a long-term care center. Personal attributes to include professionalism, neatness, attention to detail, organization, accuracy, the ability to articulate pleasantly and cooperation with all staff. Must present a neat, clean, professional appearance and demonstrate a positive, cheerful attitude towards Team Members, Residents, and others.

Work Environment

The work environment characteristics described here are representative of those a Team Member encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work under pressure and manage multiple tasks. Able to operate standard office equipment; works in clean, well-lit, heated and cooled office area. Could be subjected to exposure to hazardous chemicals or infectious substances.