Director 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.