Health Information Manager / Restorative Nurse

Signature HealthCARE, LLC•Bardstown, KY

About The Position

Signature HealthCARE at Colonial Rehab & Wellness Center is a 69-bed facility offering services from short-term rehabilitation to traditional long-term care. The organization focuses on resident-centered healthcare, personalized spirituality, and quality-of-life initiatives. The Health Information Manager / Restorative Nurse assists in maintaining residents’ medical records in accordance with facility policies and state and federal regulations, and serves as the facility’s designated Compliance Liaison. The role manages medical records throughout their lifecycle, supports accurate and timely documentation, maintains confidentiality and regulatory compliance, coordinates record requests, and assists with compliance communications and activities.

Requirements

Associate degree or higher in Health Information Management, Healthcare Administration, or a related field from an accredited college; extensive Health Information experience may be considered instead of a degree.
At least two years of experience in a healthcare facility.
Knowledge of legal, ethical, and professional practice standards applicable to Health Information Management.
Knowledge of medical terminology, anatomy and physiology, and regulatory requirements.
Strong analytical, critical-thinking, and problem-solving skills.
Intermediate to advanced proficiency in Microsoft Word, Excel, PowerPoint, and Outlook.
Professionalism and personal integrity, with the ability to exercise independent judgment and maintain confidentiality.

Nice To Haves

Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) credential.
Experience in a skilled nursing facility or other long-term care setting with Health Information Management.
Experience with an EMR and/or MatrixCare.

Responsibilities

Manage medical records from admission through discharge and long-term storage, ensuring accuracy, timeliness, completeness, security, and regulatory compliance.
Upload paper-based patient records to the electronic chart promptly upon receipt.
Maintain organized auxiliary clinical and administrative records in accordance with company retention policy.
Prepare, label, and send paper documents to offsite storage in accordance with retention schedules; assist with locating and retrieving stored records.
Follow up with hospitals and external providers to obtain documentation after transfers or appointments and ensure it is included in patient charts.
Track physician visits, obtain missing visit notes, and escalate delays to facility management.
Conduct routine audits of required documentation, present findings in daily morning meetings, follow up on deficiencies, and incorporate results into QAPI reporting.
Forward record requests to facility management within 24 hours and communicate with requestors as needed.
Retrieve and release records in response to approved requests, following company policy and confidentiality standards.
Advise staff and leadership as a subject matter expert on health information management standards and regulations.
Serve as the facility Compliance Liaison.
Assist with the annual Compliance risk assessment by reminding stakeholders to complete the annual survey.
Remind stakeholders of annual Compliance education deadlines.
Periodically distribute the code of conduct and compliance policies.
Distribute the Compliance Newsletter and Compliance Tips monthly.
Escalate allegations of Code of Conduct or policy violations to the compliance office and assist with compliance investigations when requested.
Serve as a communication channel between the facility and compliance office and assist the compliance officer with compliance questions.
Meet the stated physical and sensory requirements and work in the described environment.
Provide positive customer service to internal and external customers.
Identify and participate in process improvement initiatives.
Complete other special projects and duties as assigned.