Job DetailsJob Location: CLINTON, NY 13323Salary Range: $65,000.00 - $75,000.00 Salary/yearJob Shift: DayDirector of Health Information Management Department: Health Information Management Reports To: Chief Information Officer (CIO) FLSA Status: Exempt Position Summary The Director of Health Information Management is responsible for the leadership and oversight of the Health Information Management Department. The Director ensures the integrity, accuracy, confidentiality, security, and availability of resident health information while supporting regulatory compliance, reimbursement, documentation integrity, and quality resident care. The position serves as the facility Privacy Officer and collaborates with clinical and operational leaders to ensure compliance with health information management standards and applicable federal and New York State regulations. Essential Responsibilities Direct and oversee all Health Information Management operations. Ensure resident medical records are complete, accurate, timely, and maintained in accordance with regulatory requirements. Oversee the electronic health record (EHR) system and promote documentation integrity. Review active and discharged medical records for completeness prior to permanent electronic storage. Oversee ICD-10-CM coding accuracy and perform coding functions as needed. Collaborate with MDS, Nursing, Therapy, Finance, and the Business Office to support accurate reimbursement, Case Mix, PDPM, and Triple Check processes. Maintain facility census information and prepare statistical and operational reports. Coordinate physician documentation, signatures, and required regulatory documentation. Manage release of information requests, subpoenas, insurance reviews, RAC audits, and government record requests. Maintain medical records according to retention, destruction, confidentiality, and HIPAA requirements. Coordinate, prepare, or oversee required state and federal reporting, including Health Commerce System submissions, CDC reporting, NYSIIS, Death Registry, Case Mix, and other required reports. Compile and analyze HIM data to support QAPI and organizational performance improvement. Serve as the organization's Policy Coordinator by maintaining and updating policies and procedures. Support survey readiness, mock surveys, plans of correction, and regulatory audits. Collaborate with interdisciplinary departments to improve documentation quality and regulatory compliance. Supervise, mentor, coach, and evaluate HIM staff. Develop departmental goals, budgets, and performance improvement initiatives. Travel between Community Wellness Partners campuses as needed. Perform additional responsibilities consistent with the scope of the position and organizational needs. Â QualificationsQualifications Education Associate's or Bachelor's Degree in Health Information Management, Health Administration, Nursing, Business Administration, or a related healthcare field preferred. Licensure/Certification Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred. ICD-10-CM coding certification or equivalent coding experience required. Certified in Healthcare Compliance (CHC) or Certified Compliance & Ethics Professional (CCEP) preferred. HIPAA Privacy certification preferred. Experience Minimum of three (3) to five (5) years of progressively responsible experience in Health Information Management within a skilled nursing facility or long-term care setting. Experience managing Electronic Health Records, coding, documentation integrity, regulatory reporting, and reimbursement processes. Experience administering or supporting a healthcare compliance program preferred. Knowledge, Skills, and Abilities Thorough knowledge of anatomy, physiology, medical terminology, ICD-10 coding principles, and long-term care documentation requirements. Comprehensive understanding of CMS, Medicare, Medicaid, HIPAA, OSHA, New York State regulations, and healthcare compliance requirements. Demonstrated ability to conduct audits, analyze regulations, interpret compliance requirements, and implement corrective actions. Excellent leadership, organizational, analytical, communication, and problem-solving skills. Ability to maintain confidentiality and exercise sound professional judgment. Proficiency with Microsoft Office applications and Electronic Health Record systems. Ability to work independently while effectively collaborating with interdisciplinary teams. Physical Requirements Ability to sit, stand, walk, bend, reach, and move throughout the facility during the workday. Ability to lift, push, pull, or move up to twenty-five (25) pounds. Ability to use standard office equipment and computer systems. Ability to respond appropriately during emergency situations and assist as directed. Â Working Conditions Office environment within a skilled nursing and rehabilitation organization. Frequent interaction with residents, families, physicians, interdisciplinary staff, auditors, surveyors, attorneys, and regulatory agencies. Occasional exposure to infectious diseases and other healthcare-related hazards; adherence to infection prevention and control practices is required.
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