Medical Records

PACS

About The Position

The Medical Records Director oversees the management, security, and accuracy of resident health records in a skilled nursing facility. The role ensures timely documentation, supports clinical and administrative staff, and maintains the confidentiality and integrity of medical information in compliance with federal, state, and facility regulations. The position manages resident records and related documentation, oversees electronic health record systems, handles medical-record requests, and supports audits and survey readiness. The director may supervise medical records staff, including providing training, scheduling, and performance oversight.

Requirements

At least 2 years of experience in medical records or health information management; long-term-care experience is preferred.
Strong knowledge of HIPAA, Medicare/Medicaid documentation standards, and skilled nursing facility regulations.
Proficiency in EHR systems and Microsoft Office.
Excellent organizational, communication, and problem-solving skills.
Ability to manage multiple priorities and meet deadlines.
Frequent sitting, typing, and reviewing documents; occasional walking, standing, and lifting up to 25 pounds.
Ability to focus in a busy environment and handle confidential information with discretion.

Nice To Haves

Associate or bachelor’s degree in Health Information Management.
Certification as a Registered Health Information Technician (RHIT) or similar credential.
Experience in long-term care.

Responsibilities

Manage the creation, maintenance, and storage of resident medical records in accordance with HIPAA and regulatory guidelines.
Ensure timely and accurate documentation of admissions, discharges, transfers, and clinical updates.
Monitor record completion and compliance with facility policies and state and federal requirements.
Coordinate with nursing, therapy, and administrative teams to support documentation needs.
Handle medical-record requests from residents, families, legal representatives, and outside providers.
Oversee electronic health record (EHR) systems and troubleshoot documentation issues.
Train and supervise medical records staff, if applicable; provide training, scheduling, and performance oversight.
Prepare reports and audits for internal and external review.
Maintain confidentiality and safeguard sensitive health information.
Support survey readiness and respond to documentation-related inquiries from regulatory agencies.