- Provide expertise on compliance issues and the integration of clinical documentation and coding with the billing process.
- Provide assistance and function as a key resource/project manager for the development, transition, and maintenance of an electronic health record
- Assist with implementation and function as a key resource on the Health Insurance Portability and Accountability Act (HIPAA) including information system security issues and privacy.
- Develop, implement and monitor health information department policy and procedures and job descriptions.
- Provide training and orientation to health information personnel on functions of the department and facility staff on documentation.
- Develop and maintain health information systems and processes that meet regulatory requirements (both state and federal), professional practice standards, legal standards, and management/corporate policy.
- Establish a process for systematically reviewing documentation on an ongoing basis for both quality and quantity of documentation.
- Complete documentation/medical record audits and monitoring with an ability to assess the quality of documentation.
- Recommend corrective actions for findings on medical record audits/monitoring.
- Initiate clinical record systems and indexes.
- Assist with forms development and forms analysis/flow.
- Support compliance process of facility/organization.
- Support quality assurance/quality improvement process of the facility/organization.
- Train staff on quality assurance/quality improvement process related to health information management and appropriate methods for the collection of data.
- Provide resources to the facility on health information, documentation, regulations, standards of practice, etc.
So who are health information professionals? We are credentialed professionals who manage individual health records as well as aggregate data. We carry expertise in health care databases, medical classification systems, flow of clinical information, medico-legal issues, uses of health information, and data security systems. Our common purpose is to provide reliable and valid information that drives the healthcare industry. We are specialists in administrating information systems, managing medical records, coding information for reimbursement and research. We are uniquely qualified to:
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