Director HIM, Coding & CDI

SCOPE OF POSITION:

Reporting to the Regional Chief Financial Officer & Senior Vice President Finance & Revenue Cycle, the Director of Health Information Management (HIM), Coding, and Clinical Documentation Improvement (CDI) is responsible for overseeing the HIM department, ensuring accurate coding and optimal clinical documentation, and ensuring the implementation and maintenance of standards for compliance, regulatory requirements, and quality assurance. The role involves leadership, strategic direction, and operational management of coding, documentation practices, and related processes to improve the quality of patient data for reimbursement, clinical outcomes, and patient care.

RESPONSIBILITIES:

• Lead, manage, and direct the HIM, coding, and CDI teams in the implementation of processes and best practices for clinical documentation, coding accuracy, and compliance with healthcare regulations.
• Develop and implement strategies to optimize coding productivity, accuracy, and reimbursement while maintaining compliance with legal and regulatory requirements.

• Collaborate with senior leadership to ensure HIM, coding, and CDI functions align with organizational goals and priorities.
• Develop departmental goals, objectives, and performance metrics, ensuring alignment with overall hospital or healthcare facility goals.
• Oversee the coding processes for inpatient, outpatient, and specialty services, ensuring compliance with ICD-10-CM/PCS, CPT, and HCPCS coding systems.
• Implement and oversee the Clinical Documentation Improvement (CDI) program to ensure documentation accurately reflects the patient’s diagnoses, procedures, and overall care.
• Review and provide feedback on clinical documentation to improve completeness and accuracy, ensuring it supports appropriate coding and reimbursement.
• Ensure that coding and CDI staff are up to date with coding guidelines, payer-specific requirements, and regulatory changes (e.g., CMS, OIG, HIPAA).

• Ensure adherence to HIM, coding, and CDI policies and procedures, and compliance with federal and state regulations (HIPAA, CMS, OIG, etc.).
• Oversee audits of coding and clinical documentation to ensure adherence to accuracy standards and identify potential areas of risk.
• Develop and implement corrective action plans for any deficiencies or areas of non-compliance discovered during audits.
• Maintain up-to-date knowledge of changes in healthcare regulations and coding standards and communicate them to the team as needed.

• Work closely with clinical staff, including physicians, nurses, and other healthcare professionals, to ensure accurate and complete documentation of patient care.
• Coordinate with other departments, including Revenue Cycle, Finance, Quality, and IT, to optimize documentation practices, coding accuracy, and billing procedures.
• Provide regular reports on coding accuracy, CDI performance, and audit results to leadership and key stakeholders.

• Recruit, train, and manage a team of coding professionals, CDI specialists, and HIM staff, ensuring high levels of performance and job satisfaction.
• Provide ongoing education and professional development opportunities for the team to keep up with changes in coding guidelines, documentation practices, and industry trends.
• Foster a collaborative and positive work environment that promotes teamwork and continuous improvement.

REQUIREMENTS:

• Bachelor’s degree in Health Information Management, Healthcare Administration, or a related field (master’s degree preferred).
• Extensive knowledge of ICD-10, CPT, HCPCS coding systems, and clinical documentation requirements.
• Certification as a Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), or equivalent certification is highly preferred.
• Seven to ten (7-10) years of progressive management experience in HIM required.

• Strong leadership skills with the ability to motivate and manage teams effectively.
• In-depth knowledge of healthcare regulations, coding standards, and compliance requirements (CMS, HIPAA, OIG, etc.).
• Excellent communication, presentation, and interpersonal skills to work effectively with physicians, clinical staff, and leadership.
• Strong analytical and problem-solving skills with the ability to assess complex data and make informed decisions.
• Ability to work in a fast-paced environment, manage multiple priorities, and meet deadlines.
• Proficiency with HIM and coding software, electronic health record (EHR) systems, and Microsoft Office Suite.
• Experience with 3m 360 and Cerner preferred.
• Knowledge and experience in information privacy laws, access, release of information, and release control technologies.