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Manage the collection, accuracy, confidentiality, and timely maintenance of all resident medical records in compliance with HIPAA and CMS standards, including daily census reporting, documentation audits, and coding (ICD-10)
Develop, review, and update policies related to the security and confidentiality of Protected Health Information (PHI)
Conduct regular audits to ensure regulatory compliance and prepare for CMS/state surveys and inspections
Oversee scanning, uploading, and organization of resident documentation into the EHR system (e.g., PointClickCare)
Monitor physician documentation (e.g., H&Ps, TB tests, therapy notes), and obtain external provider signatures as needed
Assign diagnosis codes and track referral sources and payer types to support accurate billing and reimbursement
Ensure medical records support MDS assessments and care planning
Lead the HIM and reception/unit secretary team, including hiring, training, scheduling, evaluation, and discipline
Ensure front desk coverage during business hours and orient new staff to the HIM department and facility procedures
Manage the HIM department budget, maintain supply cost-efficiency, and contribute to facility-wide goals and QAPI initiatives by aligning HIM activities with quality and operational priorities
Requirements
High School Degree or equivalent required
Associates or Bachelor's degree in Health Information Management, Health Administration, or related field strongly preferred
Minimum 3 years of experience in health information management, with at least 1 year in a skilled nursing or long-term care setting
Possess current or has the ability to obtain a Level 1 Fingerprint Clearance Card
What we offer
Comprehensive health benefits (Medical, Dental & Vision)
401k with immediate vesting and up to 4% employer match
Tuition Reimbursement
Exclusive discounts through The Employee Network
Access to the Employee Association, supporting team members in need