The Health Information Manager / Medical Records Director at Serenity Oaks IRF is responsible for the management, integrity, accuracy, and security of all patient health records in compliance with CMS IRF CoPs, CARF accreditation standards, HIPAA, and Louisiana LDH/DHH regulations. This role leads the HIM department, oversees medical coding and IRF-PAI accuracy, manages release of information, and ensures the completeness and timeliness of the medical record. The HIM Director serves as the facility's designated HIPAA Records Custodian and plays a vital role in supporting revenue cycle integrity and regulatory compliance.
2. ESSENTIAL FUNCTIONS & RESPONSIBILITIES
- Direct and manage all HIM department operations including medical records processing, coding, release of information, and record retention.• Ensure completeness, accuracy, and timeliness of all inpatient medical records per CMS, CARF, HIPAA, and LDH requirements.• Oversee ICD-10-CM/PCS coding accuracy and IRF-PAI coding compliance; coordinate coding queries with the clinical team.• Serve as the facility's designated HIPAA Privacy Records Custodian; manage release of information requests per HIPAA regulations.• Manage the medical record deficiency tracking system; ensure timely physician completion of outstanding documentation.• Coordinate with the billing team to ensure documentation supports IRF-PPS reimbursement and CMG assignment.• Develop, implement, and annually review HIM policies and procedures.• Recruit, supervise, evaluate, and develop HIM department staff.• Maintain the medical record retention schedule in compliance with Louisiana LDH and HIPAA requirements.• Coordinate HIM activities related to CMS, CARF, and LDH survey preparation.• Manage electronic health record (EHR) system functions within HIM scope; coordinate with IT on record-related system issues.• Participate in CARF program evaluation activities related to health information management.• Oversee the management and security of both electronic and paper records.• Prepare HIM department reports and metrics for leadership review.
3. EDUCATION & EXPERIENCE REQUIREMENTS
- Required: Bachelor of Science in Health Information Management (BSHIM) from a CAHIIM-accredited program; or equivalent degree.• Required: RHIA (Registered Health Information Administrator) credential from AHIMA required or in progress.• Preferred: Two (2) or more years of HIM management experience in an acute care or IRF setting.• Preferred: Experience with IRF-PPS, CMG coding, and IRF-PAI documentation.
4. LICENSURE, CERTIFICATION & REGISTRATION REQUIREMENTS
- Required: Registered Health Information Administrator (RHIA) credential from the American Health Information Management Association (AHIMA); or RHIT with demonstrated management experience.• Preferred: Certified Coding Specialist (CCS) from AHIMA.• Required: RHIA/RHIT credential verified through AHIMA prior to and throughout employment.
5. KNOWLEDGE, SKILLS & ABILITIES
- Comprehensive knowledge of health information management principles and medical record standards.• Expert knowledge of ICD-10-CM/PCS coding and IRF-PAI CMG coding requirements.• Thorough understanding of HIPAA Privacy and Security Rules applicable to medical records.• Knowledge of CMS IRF CoPs related to medical records and documentation requirements.• Familiarity with CARF standards related to health information management.• Proficiency with EHR systems and HIM software applications.• Strong supervisory and staff development skills.• Knowledge of Louisiana LDH medical record retention requirements.
6. PHYSICAL DEMANDS & WORKING CONDITIONS
- Primarily office environment; primarily sedentary with frequent computer use.• Frequent walking for department oversight and coordination with clinical areas.• Occasional lifting of medical record files up to 25 lbs.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in accordance with the Americans with Disabilities Act.
7. COMPLIANCE & REGULATORY ACKNOWLEDGEMENTS
- Serve as designated HIPAA Privacy Records Custodian; ensure full HIPAA compliance in all HIM activities.• Adhere to Serenity Oaks Corporate Compliance Program and Code of Conduct.• Mandatory reporter under Louisiana law for abuse, neglect, and exploitation.• Participate in CARF program evaluation activities related to HIM.• Ensure medical record compliance with CMS IRF CoPs.• Comply with Louisiana LDH/DHH medical record regulations.
8. EQUAL EMPLOYMENT OPPORTUNITY STATEMENT
Serenity Oaks Inpatient Rehabilitation Facility is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law.
Job Types: Full-time, Contract
Expected hours: 40 per week
License/Certification:
Work Location: In person
