Health Information Administrator at IDOC Centralia Correctional Center (2021-07 – 2023-12)
- Assisted in the development of new administrative systems, procedures and policies.
- Managed office supplies inventory and placed orders when necessary.
- Maintained filing system for important documents such as contracts and invoices.
- Coordinated meetings for health care unite
- Provided general administrative support to staff members.
- Prepared reports on various projects for management review.
- Updated databases
- Created presentations using Microsoft PowerPoint for senior management team members.
- Performed data entry tasks into computer databases from paper documents.
- Developed spreadsheets to track project progress, budgets and other related data.
- Monitored emails, sorted mail and distributed correspondence accordingly.
- Compiled statistical data from a variety of sources for analysis purposes.
- Ensured that all paperwork was completed accurately before submission deadlines.
- Designed forms and templates to streamline workflow processes within the organization.
Health Information Management Technician at IDOC Menard Correctional Center (2014-09 – 2021-06)
- Reviewed medical records for accuracy and completeness, ensuring compliance with HIPAA regulations.
- Maintained a secure database of patient information, including diagnoses, treatments, insurance information, and other health data.
- Performed quality control checks to ensure accuracy of data entry into electronic health record system.
- Developed and implemented policies and procedures to ensure accurate coding of medical records according to ICD-10 guidelines.
- Conducted audits of medical charts to identify deficiencies in documentation or coding accuracy.
- Generated periodic reports summarizing patient care activities across multiple departments within the organization.
- Retrieved medical records upon request from patients or authorized personnel.
- Prepared release forms for transferring confidential medical records between providers.
- Tracked requests for medical records from third party payers and other organizations.
- Updated patient files with current medications prescribed by provider orders.
- Worked with physicians and nurses to find methods to improve quality of patient health documents and records.
- Protected medical information against unauthorized access, loss or corruption by consistently following security protocols.
Medical Records Director at Wexford Health Services (2013-08 – 2014-09)
- Developed, implemented and maintained medical records policies and procedures.
- Reviewed medical records for accuracy, completeness and compliance with applicable laws and regulations.
- Conducted audits of medical records to identify areas needing improvement or corrective action.
- Trained staff on proper use of the electronic health record system.
- Ensured timely release of information in accordance with federal and state laws, accreditation standards, organizational policy and other regulatory requirements.
- Maintained accurate inventory control systems for all paper-based medical records.
- Analyzed data from various sources including physician orders, laboratory results, radiology reports, to ensure complete documentation within patient's chart.
- Identified opportunities for improvement in processes related to medical records management.
- Developed workflow processes that ensured efficient utilization of resources while maintaining high quality standards.
Administrative Staff Assistant at Wexford Health Services (2012-04 – 2013-08)
- Maintained records management systems by filing documents, retrieving data as requested, and ensuring accuracy of information.
- Prepared correspondences such as memos, letters, reports, emails, faxes and other documents for internal use or external distribution.
- Scheduled meetings and appointments for staff members as needed.
- Created purchase orders in accordance with approved budget guidelines.
- Provided administrative support to executives by preparing agendas for meetings; taking minutes; organizing paperwork; maintaining calendars; scheduling appointments; making travel arrangements; coordinating events.
- Performed general clerical duties such as photocopying, scanning, faxing and mailing documents.
- Received incoming mail and packages daily and distributed accordingly.
- Managed office equipment maintenance contracts with external vendors.
- Developed filing systems for hard copy documents to improve efficiency of document retrieval process.
Medical Records Director at Wexford Health Services (2011-08 – 2012-04)
- Developed, implemented and maintained medical records policies and procedures.
- Reviewed medical records for accuracy, completeness and compliance with applicable laws and regulations.
- Evaluated patient care documentation to ensure accuracy of data entry.
- Conducted audits of medical records to identify areas needing improvement or corrective action.
- Collaborated with physicians, nurses and other healthcare professionals to improve quality of patient care documentation.
- Ensured timely release of information in accordance with federal and state laws, accreditation standards, organizational policy and other regulatory requirements.
- Provided education on HIPAA regulations related to access and disclosure of protected health information.
- Resolved complex issues related to medical record retrieval requests from external sources such as attorneys, insurance companies or government agencies.
CDI Specialist at SIH Herrin Hospital (2009-09 – 2011-08)
- Researched and analyzed customer feedback to identify areas of improvement.
- Reviewed medical records to ensure accuracy and completeness of clinical documentation.
- Conducted patient interviews to obtain additional information for medical record entries.
- Analyzed data from multiple sources including laboratory, radiology and pathology reports.
- Identified discrepancies in documentation with providers and resolved inconsistencies in a timely manner.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Developed and implemented policies and procedures related to clinical documentation improvement initiatives.
- Provided education to healthcare professionals on proper utilization of ICD-10 codes and other relevant coding guidelines.
- Reviewed all discharge summaries to ensure they meet quality standards as defined by the Joint Commission.
- Collaborated with interdisciplinary teams to identify opportunities for improvement in clinical documentation processes.
- Generated monthly reports that reflect performance metrics related to CDI activities.
- Identified areas of risk related to incomplete or inaccurate documentation practices.
- Participated in regular meetings with physicians, nurses, case managers, coders, therapists to discuss changes or improvements needed for clinical documentation processes.
- Maintained current knowledge of ICD-10 coding requirements, CPT and HCPCS coding systems, DRG assignment criteria and CMS regulations.
- Compiled data from various sources such as EMRs, physician notes and other documents into a single source document.
