Health Information Specialist – Skilled Nursing / Long-Term Care (On-Site)

About the position

Health Information Manager – Long-Term Care Community. Bring your expertise to a place that values quality, compassion, and regulatory excellence. As our Health Information Specialist, you'll be a key member of the leadership team, guiding the flow and integrity of resident health records in a supportive, skilled nursing environment. This is an opportunity to make a meaningful impact—ensuring accurate documentation that supports resident care, survey readiness, and interdisciplinary coordination.

Responsibilities

• Oversee and maintain resident-centered medical records from admission to discharge
• Prepare and audit documentation for new admissions and clinical transitions
• Monitor and ensure timely physician certifications and recertifications for skilled stays
• Safeguard protected health information and manage secure access to medical records
• Conduct regular audits and ensure compliance with CMS and state LTC regulations
• Train staff on documentation practices, privacy standards, and evolving LTC policies
• Collaborate daily with nursing, MDS, therapy, and administrative teams to ensure accuracy and completeness
• Manage retention, storage, and destruction of health records per LTC guidelines
• Utilize electronic health record systems common to long-term care (e.g., PointClickCare)
• Support survey readiness and quality improvement initiatives across the community

Requirements

• Experience working with clinical records in a long-term care, skilled nursing, or rehab environment
• In-depth knowledge of CMS regulations, survey preparation, and interdisciplinary documentation standards
• Strong working knowledge of HIPAA and LTC-specific privacy protocols
• Proficiency with EHR platforms like PointClickCare, MatrixCare, or similar
• RHIT, RHIA, or equivalent experience preferred
• A passion for resident-focused care and attention to detail that supports compliance and quality outcomes

Nice-to-haves

• Certification as a Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred
• Minimum of 1 year of experience in long-term care health information management or equivalent setting
• Strong understanding of Medicare, Medicaid, and HIPAA regulations related to resident records (preferred)
• Proficient in Microsoft Office (Word, Excel, Outlook), with experience in electronic health record (EHR) systems — knowledge of PointClickCare is a plus
• Excellent customer service and interpersonal skills — works well with residents, families, and interdisciplinary team members
• Detail-oriented, organized, and able to manage time and priorities in a fast-paced environment

Benefits

• Health Coverage
• Health Savings Accounts
• Retirement (with match)
• Dental, Vision, Disability & Life Insurance
• Paid Time Off plan