About The Position

Medical Hill Healthcare Center is seeking a detail-oriented and clinically licensed LVN to lead our Medical Records Department. This role is critical in ensuring the integrity, confidentiality, and regulatory compliance of our resident health information. The ideal candidate combines clinical knowledge with administrative excellence to support our interdisciplinary team and ensure our facility remains survey-ready at all times.

Requirements

  • Current California Licensed Vocational Nurse (LVN) license (Required).

Nice To Haves

  • Previous experience in Medical Records or Health Information Management (HIM) within a skilled nursing or post-acute setting is highly preferred.

Responsibilities

  • Manage the creation, maintenance, and secure storage of resident medical records in strict accordance with HIPAA and regulatory guidelines.
  • Ensure timely and accurate documentation of all admissions, discharges, transfers, and clinical updates.
  • Monitor record completion for compliance with facility policies and state/federal requirements; prepare reports and audits for internal and external review.
  • Act as a liaison between nursing, therapy, and administrative teams to support all documentation and clinical data needs.
  • Process and handle requests for medical records from residents, families, legal representatives, and outside healthcare providers.
  • Oversee Electronic Health Record (EHR) systems, troubleshooting documentation issues and ensuring data integrity.
  • Support the facility during regulatory surveys and respond to documentation-related inquiries from state and federal agencies.
  • Train and supervise medical records staff (if applicable) to maintain department standards.
  • Maintain the highest level of confidentiality and safeguard all sensitive health information.
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