Director of Health Information

The Director of Health Information is responsible for maintaining resident medical records in accordance with federal and state regulations, professional standards of practice, HIPAA requirements, and company policies and procedures. This position oversees the management, integrity, accuracy, confidentiality, and accessibility of resident health information from pre-admission through post-discharge while supporting regulatory compliance, quality care, and reimbursement processes. Essential Responsibilities Health Information Management Ensure resident medical records remain accurate, complete, current, and confidential. Maintain compliance with all federal and state regulations, HIPAA requirements, and company policies and procedures. Manage resident health information processes from pre-admission through post-discharge. Create and maintain medical records for all new admissions. Establish and implement procedures for the collection, coding, indexing, filing, storage, and retrieval of medical records. Ensure resident records are maintained accurately and timely according to local, state, and federal regulations. Maintain admission and discharge registries and ensure all required documentation is properly recorded and filed. Protect medical records from breaches of confidentiality and unauthorized access. Coding and Documentation Ensure accurate and current diagnostic coding to support appropriate billing, maximize accounts receivable, and improve cash flow. Perform ICD coding and maintain coding accuracy in accordance with applicable regulations and guidelines. Monitor documentation practices to support reimbursement and regulatory compliance. Quality Assurance and Compliance Conduct monthly audits of admissions, discharges, and routine quality assurance documentation. Monitor medical records for completeness and regulatory compliance. Promptly report concerns and suspected incidents of non-compliance to the supervisor, Compliance Liaison, or Compliance Officer through the Integrity Hotline. Participate in facility orientation, ongoing education, and required training programs. Collaborate with interdisciplinary teams to ensure documentation standards are maintained. Communication and Collaboration Maintain positive working relationships with residents, families, staff, physicians, consultants, healthcare providers, governmental agencies, and community representatives. Serve as a resource regarding medical record regulations, documentation standards, and health information practices. Qualifications Required RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician) credential. Minimum of two (2) years of experience in medical records within a skilled nursing facility, hospital, or healthcare-related setting. Knowledge of federal and state laws and regulations governing medical records and long-term care. Strong understanding of medical terminology. Excellent organizational, analytical, and communication skills. Ability to maintain confidentiality and handle sensitive information professionally. Preferred Experience with ICD coding. Experience in long-term care, skilled nursing, and/or hospital environments. Knowledge of electronic health record (EHR) systems and electronic documentation. Benefits We offer a comprehensive benefits package that may include: 401(k) Retirement Plan Health Insurance Dental Insurance Vision Insurance Life Insurance Paid Time Off (PTO) Tuition Reimbursement Employee Appreciation Events Modified Workers' Compensation Program Equal Opportunity Employer We are committed to creating a diverse and inclusive workplace. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected characteristic under applicable law.