Highly knowledgeable health information management professional with expertise in medical records management, coding, data entry and data proofreading. Proven ability to review and analyze clinical data, ensuring accuracy and compliance. Well-versed in ICD-10, CPT and HCPCS coding systems. Gained a wealth of healthcare experience and an expert in problem-solving. Talented in maintaining complex and comprehensive databases covering patient information. Dedicated to proactive monitoring and thorough reporting using top-notch technical abilities.
Serve as the Chief Medical Record Administrator responsible for the management of the Bay Pines VA Healthcare System's health record program. Having responsibility for and complete oversight of all sections in the Health Information Management Service at each division, Community Based Outpatient Clinics and various contract services. Act as key advisor to the Chief of Staff, Executive Management, and provide technical guidance on health information issues. Manage and directly supervise all personnel working within the health information program, including, the coding unit, medical records/scanning unit, release of information and CDI units. Responsible for maintenance and evaluation of health records and assuring legal requirements for care are met. Provide direct support to Regional Counsel, assist in developing and coordinating internal review systems to ensure both clinical and administrative activities follow agency, accrediting and regulatory requirements.
Medical Records Subcommittee meeting chair, also a participant in several multi-functional work group meetings with Quality Management and Providers. Review and analyze quality metrics data, and make recommendations for improving our facility's performance metrics. Team member, RAPID Improvement Project, tasked with ascertaining root cause analysis of documentation issues and making recommendations for improvement. Analyze healthcare related reports and present findings, conclusions, and recommendations to the Compliance Officer. Develop SMART goals, objectives and action plans for the Health Information Management Service, present detailed oral and written reports to the Strategic Planning Council.
HIM subject matter expert and consultant on all issues relating to the understanding and interpretation of Joint Commission standards and other regulatory agency requirements pertaining to Health Information. Responsible for determining staffing and equipment needs, supervision of personnel, coordinating efforts with other Services and Sections. Assist in managing assigned budget and resources, completing performance evaluations, interviewing and hiring staff to fill vacancies.
Leverage data and analytics to make informed decisions and drive business improvements.
Direct subordinate managers in day-to-day performance of groups involved in operation and maintenance. Plan, direct and control execution of administrative and compliance activities. Allocate duties and activities of personnel, manage contractual agreements and associated deliverables through oversight and inspection. Cultivate positive rapport with fellow employees to boost company morale and promote employee retention. Identify areas of personnel deficiency and take necessary action for correction.
Develop long-term relationships through focused effort on customer's unique needs and finding best solutions. Assume active role in identifying opportunities to develop and implement projects which promote organization's missions and functions. Evaluate employee performance and convey constructive feedback to improve skills. Recruit, interview and hire employees and create mentoring program to promote positive feedback and engagement.
Provide oversight of all coding staff, with administrative responsibility for planning and assigning workload, and ensuring that turnaround time is being met. Hire, train, evaluate and provide support for coding staff. Review audit results and provide education and training based on the results of the audit. Ensure that coders are improving and maintaining coding accuracy as per National standard. Monitor coding staff to ensure that coding guidelines are being followed, areas of weakness identified and opportunity for improvement is provided. Create action plan for coding backlog, report to upper management and Central Office. Plan, organize, direct and control areas with emphasis on data validation, analysis, and generation of reports.
Participate in committee meetings to discuss electronic health records and methods to improve overall workflows. Collaborate closely with physicians and nursing staff to improve quality of clinical documentation. Retrieve medical record data for physicians and patients. Conduct education and training activities for physicians, nursing staff and administrative personnel. Participate in monthly Compliance meetings and Medical Staff Committee meetings.
Generate medical record reports on patient admissions, treatment and discharge for the Cancer Registry. Perform regular quality and validation assessments on patient data to verify accuracy. Uphold HIPAA regulations and standards for protecting patient information. Secure confidential patient information from unauthorized access.
Audit Physicians’ clinical documentation weekly, communicate and provide education when documentation is inadequate for coding. Liaise with coders to ensure queries sent to Physicians are appropriate; audit Inpatient records to ensure that Physicians queries are answered timely. Analyze and extract data from discharged accounts entered into the legal electronic medical records. Oversee the Physician suspension process.
Provide key support during merger and transition from facility’s old legacy system to new organization’s existing EMR (HPF McKesson to Cerner). Act as super user for Providers, and other non-clinical staff during "Go Live".
Budgeting
undefinedRegistered Health Information Administrator(RHIA)
Registered Health Information Administrator(RHIA)