Quality Nurse/Medical Records Nurse

Job Description

Job Description

The Quality Nurse / Health Information Management (HIM) Director is responsible for the oversight, coordination, and continuous improvement of clinical quality, patient safety, and health information management functions within the facility. This role integrates Quality Assurance and Performance Improvement (QAPI) activities with medical record integrity and regulatory compliance, ensuring alignment with the Centers for Medicare & Medicaid Services Conditions of Participation, The Joint Commission standards, and all applicable state regulations. Reporting directly to the Hospital Administrator and working closely with the Corporate Compliance Nurse, this position leads facility-wide quality initiatives, conducts clinical audits, and ensures the accuracy, completeness, confidentiality, and accessibility of patient health information.

The incumbent coordinates and manages the facility’s QAPI program by developing and tracking quality metrics, conducting clinical and documentation audits, identifying trends and performance gaps, and implementing corrective action plans to improve outcomes. The role facilitates QAPI and performance improvement committee activities, supports root cause analyses, ensures timely reporting of incidents and grievances, and promotes a culture of continuous improvement and survey readiness. In collaboration with nursing, medical staff, and department leaders, the Quality Nurse provides education, monitors compliance, and ensures adherence to established clinical and regulatory standards.

In the Health Information Management capacity, the position is responsible for the operational oversight of the HIM department, ensuring all medical records are maintained in a complete, accurate, and timely manner in accordance with facility policy and regulatory requirements. This includes managing chart assembly and approves closed record order, monitoring physician documentation deficiencies, ensuring record completion within required timeframes, and maintaining the secure storage and accessibility of medical records at all times. The role oversees release of information processes, ensuring proper authorization and compliance with HIPAA privacy and security requirements, and coordinates documentation workflows with external coding and billing organizations.

Additionally, the Quality Nurse / HIM Director serves as the facility’s subject matter expert on medical record content, documentation standards, and regulatory compliance, ensuring ongoing readiness for surveys and audits. The position supports the development and maintenance of policies and procedures, maintains required documentation and audit trails, and ensures that all activities are conducted in accordance with organizational policies, QAPI standards, and federal and state regulations. This role is critical to maintaining the integrity of patient care delivery and documentation, ensuring both high-quality clinical outcomes and full regulatory compliance across the organization.

Qualifications:

• Education: Graduate of an accredited School of Nursing; BSN preferred.
• Licensure: Current nursing license.
• Experience: Minimum 2 years clinical nursing experience; prior experience in Quality Improvement, Risk Management, or Infection Control preferred.
• Certifications: CPHQ (Certified Professional in Healthcare Quality) preferred.
• Skills:
  • Strong analytical and critical thinking abilities.
  • Excellent communication and presentation skills.
  • Proficient in EMR systems and data reporting tools.
  • Ability to educate and mentor clinical staff on quality practices.
  • Knowledge of CMS, Joint Commission, and state regulatory standards.
  • Proficient in Microsoft Word, Excel, Outlook, and Adobe Acrobat.
• Key Performance Indicators (KPIs):
  • Timeliness and accuracy of QAPI reports.
  • Reduction in adverse events and hospital-acquired conditions.
  • Staff education completion rates on quality initiatives.
  • Compliance scores on internal and external audits/surveys.

This position is accountable for ensuring that quality of care, patient safety, and integrity of the medical record meet or exceed all regulatory, accreditation, and organizational standards. Failure to maintain compliance may result in regulatory citations, financial penalties, or risk to patient safety , making this role critical to facility operations.

Freedom Behavioral provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.