Job Description

JD McCarty Center is an organization that provides inpatient and outpatient therapy services to children with developmental disabilities. We are currently seeking a Health Information Director to join our team!

The position requires a 40-hour work week with standard hours being Monday through Friday from 8:00 am to 4:00 pm.

Salary: Comissert with experience

Position Summary

The Director of Health Information provides strategic leadership and operational oversight for the Health Information Department. The Director is responsible for ensuring the integrity, confidentiality, availability, security, and accuracy of the organization's health information in accordance with federal and state regulations, accreditation standards, and organizational policies.

The Director oversees all functions of the Health Information Department including medical record operations, coding, documentation compliance, release of information, physician deficiency management, health information privacy, record retention, quality improvement, and electronic health record (EHR) management. The Director serves as the organization's subject matter expert regarding Health Information and collaborates with physicians, clinical departments, administration, compliance, information technology, and legal counsel to support high-quality patient care and organizational compliance.

Essential Duties And Responsibilities

Leadership and Department Operations

• Plans, organizes, directs, and evaluates all Health Information Department operations
• Supervises, mentors, and evaluates Health Information personnel
• Develops departmental goals, objectives, budgets, productivity standards, and performance measures
• Develops, reviews, and updates departmental policies and procedures to ensure compliance with current regulatory requirements and organizational needs
• Promotes continuous quality improvement within the department
• In coordination with physician chairperson, facilities the required Hospital’s Health Information Committee, to include preparation of documents and reports for the meeting

Health Information

• Ensures the integrity, completeness, confidentiality, availability, and security of all patient health information
• Oversees medical record analysis, completion, authentication, chart assembly, document imaging, indexing, record retention, and record destruction in accordance with applicable laws and regulations
• Monitors physician documentation deficiencies and delinquent medical records, providing timely reports to medical staff leadership
• Ensures medical records accurately reflect patient care and meet regulatory documentation standards

Coding and Clinical Data Integrity

• Directs and oversees all inpatient and outpatient coding activities
• Ensures accurate assignment of ICD-10-CM codes in accordance with Official Coding Guidelines, CMS regulations, payer requirements, and organizational policies
• Collaborates with providers to improve clinical documentation necessary to support accurate coding and quality reporting
• Maintains current knowledge of coding regulations and reimbursement methodologies

Regulatory Compliance

• Ensures compliance with CMS Conditions of Participation, Oklahoma State Department of Health regulations, HIPAA Privacy and Security Rules, HITECH requirements, and applicable accreditation standards
• Maintains continuous readiness for regulatory surveys and accreditation reviews
• Coordinates departmental responses to survey findings and corrective action plans
• Serves as the department's regulatory resource regarding documentation, record retention, privacy, and Health Information

Privacy and Release of Information

• Serves as the Hospital’s HIPAA compliance officer and oversees the Health Information Privacy Program
• Develops, implements, and monitors HIPAA privacy policies and procedures
• Ensures compliance with Release of Information requirements, patient rights, subpoenas, legal requests, and authorization standards
• Investigates potential breaches of protected health information and collaborates with Compliance and Legal Counsel regarding corrective actions to include any reporting as mandated by applicable laws, standards, and policies
• Coordinates HIPAA education and ongoing privacy awareness programs for workforce members

Electronic Health Record Management

• Serves as the Health Information subject matter expert for the electronic health record
• Collaborates with Information Technology and clinical departments to improve documentation workflows, document management, scanning processes, data integrity, and system optimization
• Participates in system upgrades, testing, workflow redesign, and implementation of health information initiatives
• Serves as a member on the Hospital’s Electronic Health Record Committee

Quality Improvement

• Develops, implements, monitors, and reports on performance of departmental Quality Assessment and Performance Improvement (QAPI) indicators
• Collects, analyzes, and reports performance data
• Identifies opportunities for process improvement and implements corrective actions
• Provides routine reports to leadership and organizational committees regarding Health Information QAPI results

Committee Participation

Serves as a member or chair of organizational committees including:

• Medical Records Committee
• Quality Assessment and Performance Improvement Committee
• Electronic Health Record Committee
• Medical Staff Committees, as assigned
• Additional committees as designated by administration

Education and Collaboration

• Provides education to physicians, providers, clinical staff, and employees regarding documentation requirements, coding standards, HIPAA compliance, confidentiality, and Health Information practices
• Collaborates with administration, medical staff, nursing, rehabilitation services, compliance, legal counsel, and information technology to improve organizational performance and regulatory compliance

Other Duties

Performs other duties as assigned consistent with the responsibilities of the position.

Knowledge, Skills, And Abilities

Comprehensive knowledge of:

• Health Information principles and practices
• Hospital medical record administration
• ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding systems
• Medical terminology, anatomy, and physiology
• CMS Conditions of Participation
• HIPAA Privacy and Security Rules
• Oklahoma healthcare regulations
• Electronic Health Record systems
• Release of Information requirements
• Health information privacy and confidentiality
• Quality improvement methodologies
• Regulatory survey preparedness

Ability to:

• Lead and supervise professional staff
• Interpret healthcare regulations and accreditation standards
• Analyze complex regulatory requirements
• Develop and implement departmental policies and procedures
• Prepare reports and performance metrics
• Communicate effectively with physicians, leadership, and interdisciplinary teams
• Manage multiple priorities while maintaining strict confidentiality
• Exercise sound judgment and professional discretion

Required

Minimum Qualifications

• Current Registered Health Information Technician (RHIT) credential through the American Health Information Association (AHIMA)
• Minimum five (5) years of progressively responsible Health Information experience
• Minimum three (3) years of supervisory or management experience
• Experience with electronic health records and healthcare regulatory compliance
• Bachelor's degree in Health Information, Health Administration, or related healthcare field
• Current Registered Health Information Administrator (RHIA) credential through the American Health Information Association (AHIMA)
• Pediatric hospital experience
• Rehabilitation hospital experience
• Experience with CMS surveys, accreditation surveys, and quality improvement initiatives
• Experience with hospital coding, clinical documentation improvement, and revenue cycle collaboration
• Experience working in the Evident/Trubridge/Thrive CPSI electronic health record environment

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