Health Unit Coordinator

Northern Lights is looking for a full-time Health Information Coordinator to provide loving and quality care and service to our residents living in our Assisted and Memory Care Community. The Health Information Coordinator 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 Health Information Coordinator is responsible for the oversight of confidentiality, compliance, privacy and security of the health information system and its contents.

Essential Duties and Responsibilities

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; 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 HIPPA guidelines.
• Follows regulations for retention and destruction of medical records stored in electronic format.
• 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

• Conducts audits and quality monitoring 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.
• Monitor timeliness of physician visits to ensure compliance with federal and state regulations report physicians who are out of compliance to nursing leadership.

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.
• 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 file until completed, then in complete file
• Code and index final diagnoses using the current version of the ICD.

Supervision and Management

• Discusses issues and solutions affecting Health Information department with department directors.
• Works with nursing leadership to ensure adherence to HIPPA privacy policies ad the protection of resident’s rights concerning their identifiable health care information.
• Supports and engages in QAPI initiatives; completes quarterly resident roster.