Description
Lead and direct the Health Information Management function to ensure the integrity, accessibility, privacy, coding accuracy, and lifecycle management of health records; oversee HIM operations, data governance, and regulatory compliance to support quality care, revenue cycle, and organizational reporting.
- • Direct, supervise, and evaluate HIM operations and staff, including coding, CDI, ROI, imaging, and transcription.
- • Establish departmental goals, KPIs, and quality metrics for data accuracy, timeliness, and compliance.
- • Recruit, hire, credential, and develop HIM personnel; manage training and competencies.
- • Implement, optimize, and maintain EHR/HIM systems, document imaging, and release-of-information platforms.
- • Develop, approve, and enforce policies for documentation standards, record retention, privacy, security, and data governance.
- • Plan and manage departmental budgets; authorize expenditures and oversee vendor and service contracts.
- • Set work schedules and assignments based on volumes, turnaround targets, and technology availability.
- • Coordinate with clinical leadership, IT, compliance, and revenue cycle to align documentation, coding, and data standards.
- • Monitor coding quality and productivity, chart completion, ROI turnaround, DNFB, and other HIM KPIs; implement improvements.
- • Ensure compliance with HIPAA/HITECH, CMS, Joint Commission, state regulations, and coding standards (ICD-10-CM/PCS, CPT, HCPCS).
- • Lead change management for EHR upgrades, interoperability initiatives, automation, and workflow redesign.
- • Prepare and present reports on data quality, audit results, productivity, and program status to executives and governing bodies.
- • Oversee CDI, chart deficiency management, identity management/MPI, and record lifecycle processes.
- • Engage physicians and staff to improve documentation accuracy, query response, and clinical data capture.
- • Conduct or oversee audits for coding, documentation, privacy, and ROI; mitigate risks and manage breach response.
- • Ensure physical, administrative, and technical safeguards for health information; maintain accreditation and survey readiness.
- • Analyze utilization, denial, and reimbursement data to inform revenue integrity and operational improvements.
- • Develop educational materials and deliver training on documentation standards, privacy, security, and EHR use.
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Healthcare & Human Services
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
