Director of Health Information Management (HIM) and Clinical Documentation Integrity (CDI)Nexus Health SystemsNexus Health Systems is seeking an experienced and strategic healthcare leader to serve as our
Director of Health Information Management (HIM) and Clinical Documentation Integrity (CDI). This system-level role provides leadership for health information management, coding support, and clinical documentation integrity across the organization.
The Director ensures the accuracy, completeness, confidentiality, and regulatory compliance of the legal health record while strengthening documentation practices, reducing discharged-not-final-billed (DNFB) accounts, preventing denials, and supporting accurate and timely reimbursement. This leader will collaborate closely with providers and teams across Utilization Review, Case Management, Coding, Billing, Clinical Operations, Compliance, Information Technology, and Revenue Cycle.
What You Will DoHIM and CDI Leadership- Provide strategic and operational leadership for HIM and CDI functions across Nexus Health Systems.
- Direct daily HIM operations, including medical record completion, deficiency management, document integrity, release of information, coding support, payer record requests, record corrections, and amendments.
- Lead, develop, and evaluate HIM staff while overseeing staffing, scheduling, workload distribution, cross-training, competencies, and performance expectations.
- Establish standardized policies, workflows, productivity expectations, quality measures, and escalation procedures across the organization.
- Serve as the primary HIM subject-matter expert and escalation point for medical record integrity, documentation, disclosure, coding support, and information governance matters.
- Evaluate technology, automation, work queues, reporting tools, and workflow improvements that enhance productivity, record integrity, and revenue cycle performance.
Clinical Documentation Integrity- Lead the organization's CDI program, including targeted concurrent and retrospective documentation reviews.
- Prioritize reviews based on clinical complexity, payer risk, reimbursement impact, denial trends, and organizational needs.
- Identify documentation gaps, conflicting information, clinical validation concerns, and opportunities for greater specificity.
- Initiate compliant provider queries when documentation clarification is required.
- Educate physicians, advanced practice providers, clinical leaders, and other staff regarding documentation requirements, medical necessity, coding implications, and recurring deficiencies.
- Partner with Coding to support accurate diagnosis and procedure assignment, principal diagnosis selection, and DRG or APR-DRG validation when applicable.
- Ensure provider queries are clinically supported, appropriately written, non-leading, and compliant with established standards.
Revenue Cycle and Denial Prevention- Develop a closed-loop process among HIM/CDI, Utilization Review, Case Management, Coding, and Billing to resolve and prevent documentation, authorization, coding, and billing issues.
- Review HIM-related DNFB accounts and ensure record-completion, coding, and documentation barriers are assigned, escalated, and resolved promptly.
- Support payer audits, medical record requests, claim appeals, denials, clinical validation disputes, and reimbursement-related activities.
- Monitor denial and underpayment trends involving documentation, coding, medical necessity, and medical record submission.
- Translate findings into provider education, corrective action, and sustainable process improvements.
- Develop and communicate HIM/CDI performance metrics, operational trends, compliance risks, and financial outcomes to Revenue Cycle and executive leadership.
- Help improve clean claim submission, accelerate cash flow, and reduce preventable revenue leakage.
Compliance and Information Governance- Protect the confidentiality, integrity, availability, retention, disclosure, and appropriate use of the legal health record.
- Ensure compliance with HIPAA, applicable federal and state requirements, organizational policies, record-retention standards, and information-governance practices.
- Develop and maintain HIM/CDI policies, procedures, audit processes, and performance standards.
- Oversee routine audits involving medical record completion, documentation integrity, release of information, coding accuracy, document indexing, provider queries, and record amendments.
- Identify privacy, compliance, coding, documentation, and record-integrity risks and ensure timely escalation, investigation, corrective action, and follow-up.
- Monitor incomplete and delinquent records and implement escalation processes that support organizational record-completion standards.
- Collaborate with Compliance, Privacy, Legal, Quality, Information Technology, and clinical leadership during audits, investigations, regulatory reviews, and corrective-action initiatives.
- Support external audits, payer reviews, legal inquiries, accreditation activities, and regulatory requests involving health information.
Patient Experience and Advocacy- Ensure patients and authorized representatives receive timely, accurate, secure, and compliant access to health information.
- Provide leadership for complex release-of-information requests, amendments, subpoenas, legal requests, sensitive records, and privacy-related escalations.
- Maintain processes for correcting incomplete, inaccurate, or improperly filed information within the legal health record.
- Promote a responsive and patient-centered experience for patients, families, providers, and authorized requestors.
- Partner with clinical and operational leaders to resolve information or documentation issues that could affect patient safety, care coordination, or continuity of care.
Team and Professional Development- Build a collaborative, service-oriented HIM culture centered on accountability, responsiveness, and continuous improvement.
- Provide education, mentoring, coaching, and professional-development opportunities for HIM team members.
- Establish competency requirements and cross-training plans that promote adequate coverage and succession readiness.
- Remain current on HIM, CDI, coding, HIPAA, privacy, information governance, payer requirements, reimbursement practices, and clinical documentation standards.
- Maintain awareness of emerging technologies, automation, and artificial intelligence tools that may improve HIM, CDI, coding, and revenue cycle operations.
Qualifications- Bachelor's degree in Health Information Management, Health Information Administration, Healthcare Administration, Nursing, or a related field required; master's degree preferred.
- Active Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) credential strongly preferred.
- CDI or coding certification, such as CCDS, CDIP, CCS, or CPC, preferred.
- Progressive leadership experience in Health Information Management, Clinical Documentation Integrity, coding, revenue cycle, or a closely related healthcare function.
- Experience overseeing HIM operations and leading teams in a hospital or multi-facility healthcare environment strongly preferred.
- Strong working knowledge of HIPAA, release-of-information requirements, legal health record standards, clinical documentation, coding principles, payer audits, denials, and record-retention requirements.
- Demonstrated experience improving documentation quality, DNFB performance, coding accuracy, denial prevention, and revenue cycle outcomes.
- Ability to analyze operational and financial data, identify trends, and translate findings into measurable improvement plans.
- Strong leadership, communication, education, collaboration, and change-management skills.
- Experience working with electronic health record systems and HIM-related workflow or reporting technology.
This is an opportunity to build and strengthen an integrated HIM and CDI program with a direct impact on patient care, regulatory compliance, operational performance, and financial outcomes. You will work alongside clinical, operational, and executive leaders to create unified processes that protect the integrity of the health record and support the continued growth of Nexus Health Systems. 
