Health Information Manager

## Description

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| | | | | --- | --- | | | **Job Description** | | **Position** | Health Information Manager (LVN) | | **Department** | SNF Nursing | | **Reports To** | Director of Nursing | | **FLSA Status** | Exempt | | **Prepared By** | Human Resources | | **Prepare Date** | June 2026 | | | | | **Job Summary** | | | Under the direction of the Director of Nursing, the Health Information Manager is responsible for the overall planning, organization, management, and oversight of the facility's health information and medical records systems. This position ensures the accuracy, completeness, confidentiality, security, and regulatory compliance of resident health records in accordance with federal, state, and facility requirements. The Health Information Manager serves as a key resource for health information management, clinical documentation, regulatory compliance, quality assurance activities, and electronic health record administration. This position works collaboratively with nursing leadership, the DMS Nurse, Quality Assurance Nurse, physicians, and interdisciplinary team members to support resident care, survey readiness, and operational excellence. The Health Information Manager may supervise Medical Records staff and is responsible for maintaining the integrity of all resident health information throughout the admission, stay, discharge, and record retention process | | | **Mission and Values** | | | Demonstrates the competencies to fulfill the Mission and values of St. John of God Ministry, which are the foundation of all activities performed by every employee | | | **Mission** | We are here to extend the healing mission of Jesus through the Hospitality of St. John of God by continually improving the health and quality of life of the people we serve | | **Core Values** | | | **Hospitality** | Creates an environment where people can feel welcomed, comfortable, understood, esteemed and loves | | **Respect** | Recognizes the richness of God’s gifts and His presences in every person regardless of age, situation in life, culture or religion | | **Quality** | Works toward creating centers of excellence and service fostering continuous improvement in the quality of service | | **Responsibility** | Encourages cooperation as a way of promoting standards of competence, efficiency and accountability as we carry out our duties in the Mission | | **Leadership and Department Management** 1. Plans, develops, organizes, implements, evaluates, and directs the Medical Records and Health Information Management functions of the facility. 2. Maintains current policies, procedures, forms, and job descriptions related to health information management. 3. Reviews and updates departmental policies and procedures annually or as regulations change. 4. Supervises Medical Records staff, including hiring, training, scheduling, coaching, performance evaluations, and corrective action when necessary. 5. Attends department head meetings, quality assurance meetings, in-services, and other facility meetings as assigned. 6. Maintains effective working relationships with nursing leadership, department managers, physicians, consultants, and regulatory agencies. **Health Information Management** 7. Oversees the creation, maintenance, storage, security, retention, and destruction of resident health records in accordance with HIPAA, CMS, California Department of Public Health regulations, and facility policies. 8. Ensures timely and accurate documentation of admissions, transfers, discharges, deaths, and clinical updates. 9. Maintains resident census records and monitors record completion requirements. 10. Manages requests for release of information, subpoenas, audits, and requests from residents, families, legal representatives, physicians, hospitals, and regulatory agencies. 11. Maintains confidentiality and safeguards all protected health information. 12. Monitors record completion and follows up with physicians and interdisciplinary team members regarding missing signatures, orders, and required documentation. 13. Maintains filing systems for active and inactive records in accordance with retention requirements. 14. Maintains a master forms management system and coordinates development, review, revision, and distribution of facility forms. 15. Performs data entry and record management functions as required. **Electronic Health Records (EHR)** 16. Serves as a resource for PointClickCare and other electronic health record systems. 17. Maintains working knowledge of all aspects of the EHR system and assists with troubleshooting documentation issues. 18. Participates in planning, implementation, optimization, and future expansion of electronic documentation systems. 19. Assists staff with documentation processes and EHR-related questions. **Quality Assurance and Regulatory Compliance** 20. Participates in the Quality Assurance and Performance Improvement (QAPI) program. 21. Conducts quantitative and qualitative audits of medical records to ensure completeness, accuracy, and compliance. 22. Monitors admission, discharge, MDS, quality indicator, and survey-related documentation. | | | |