DIR - HIM/MEDICAL RECORDS

Universal Hospital Services Inc.; Raleigh (NC); On-site; USD 120,000 - 180,000; Full time

Job summary

Universal Health Services seeks a Director of Health Information Management Services to lead the HIM department, ensuring compliant management of patient records, confidentiality, and regulatory alignment across the facility.

The role requires RHIT or RHIA credentials, and at least three years of supervisory experience in health information management, preferably in a psychiatric setting. Strong leadership and collaboration with clinical staff are essential.

Qualifications

• Education: RHIT or RHIA in Health Information Management.
• Minimum 3 years supervisory experience in health information management; healthcare psychiatry facility preferred.
• Licensure: RHIA or RHIT accreditation per AHIMA.

Responsibilities

• Direct the Health Information Management Service Department within all regulatory standards.
• Coordinate with management and medical staff to maintain compliant patient records.
• Ensure confidentiality and proper release of records to authorized authorities.
• Guide staff on privacy policies and current confidentiality laws.
• Oversee staffing, hiring, and rosters to meet facility needs.
• Monitor accuracy of inpatient/outpatient records and DRG assignments.
• Serve as liaison with other hospital HIM departments and respond to inquiries.
• Maintain compliance with state/federal regulations and TJC standards.

Skills

Supervisory experience

Medical records knowledge

ICD-10 coding

Regulatory compliance

Confidentiality

Communication with management

Education

RHIT (Associate’s)

RHIA (Bachelor’s)

Job description

Responsibilities

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World’s Most Admired Companies by Fortune; listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

Qualifications

The Director of Health Information Management Services is responsible for directing the activities of the Health Information Management Services Department in the management and maintenance of all patient medical records information, ensuring compliance will all state and federal laws, rules/regulations of licensing agencies and within TJC standards for the quality of patient care.

QUALIFICATIONS

Education: Associate’s Degree (RHIT) or Bachelor's Degree (RHIA) in Health Information Management

Experience: A minimum of three (3) years’ supervisory experience in health information management is required, with direct experience in a health care psychiatric facility preferred. Thorough knowledge of medical records, release of information, ICD 10 coding Inpatient/Outpatient, the coding rules and regulations and DRG assignments and state and federal regulatory standards required.

Licensure: Certification accreditation as a registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT), as determined by the American Health Information Management Association (AHIMA).

PRIMARY RESPONSIBILITIES

1. Direct the Health Information Management Service Department within all standards established by regulatory and licensing agencies.
2. Consult with management, administration, and medical staff to ensure that all patient records are maintained within standards established by licensing agencies.
3. Maintain confidentiality of medical records, ensuring the release of files and/or records to
   only appropriate and authorized authorities.
4. Inform all facility staff of confidentiality policies pertaining to medical records and remain current on all laws and regulations regarding confidentiality of patient/medical information.
5. Direct department staff members, ensuring effective organization and completion of
6. Ensure effective departmental staffing, which may include hiring, firing, and maintaining
   staff rosters relative to changing facility needs.
7. Monitor the accuracy and appropriate maintenance of medical records on every patient, ensuing compliance with rules and regulations of state agencies, TJC on Accreditation of Health Organizations, and Medical Staff Bylaws.
8. Function as a liaison with other hospital facility Health Information Management departments.
9. Respond to inter-departmental and external inquiries and questions. Oversees all subpoenas and other legal requests pertaining to medical records. Monitor the coding of all discharged patient charts and abstract all pertinent patient information for forwarding to state agencies, as required.
10. Coordinate the preparation and/or revisions to medical record, forms, ensuring compliance with all requirements of TJC, applicable state and federal laws, Bylaws and Rules/Regulations.
11. Chairs the Health Information Management Forms Committee and/or submit all forms to the Health Information Management Records Committee for review.
12. Prepare as requested statistical reports for administration.
13. Participate in or lead various management and/or committee meetings as assigned. Assist in the abstraction and analysis of data from the medical record for medical care evaluation studies, patterns of patient care and Performance Improvement. Monitor the quality of the transcription services offered by the department, to ensure accuracy and timeliness.
14. Remain current and up to date on all laws regarding Health Information Management. Ensure the continuous professional development of self and staff, by attending professional meetings, seminars, and training.
15. Meet the requirements of the American Health Information Management Association in assuring not only active accreditation but a means of keeping abreast in the ever-changing field of Health Information Management Services.
16. Identify the educational needs of the Department Staff, the Professional Staff and other personnel and assist in the planning and teaching of classes as needed.
17. Demonstrate a professional attitude and support the objectives of the facility's guest relations philosophy through internal and external communications and interactions with all levels of staff, patients, family members, guests, and community and referral sources.
18. Adhere to facility, department, corporate, personnel, and standard policies and procedures.
19. Attend all mandatory facility in-services and staff development activities as scheduled.
20. Adhere to facility standards concerning conduct, dress, attendance, and punctuality.
21. Support facility-wide quality/performance improvement goals and objectives.
22. Acts as the facility’s Privacy Officer.
23. Maintain confidentiality of facility employees and patient information.
24. Able to abstract ICD 10 codes accurately for inpatient/outpatient accounts with a thorough knowledge of medical terminology.