Medical Records

PACS • Jourdanton, TX

1d

About The Position

The Medical Records Director oversees the management, security, and accuracy of resident health records in a skilled nursing facility, ensuring compliance with federal, state, and facility regulations. The role supports timely documentation and provides documentation support to clinical and administrative staff while maintaining the confidentiality and integrity of medical information.

The position manages resident record creation, maintenance, storage, and completion; coordinates with facility teams; handles record requests; and oversees electronic health record systems. It also supports audits, survey readiness, and regulatory inquiries. The director may supervise medical records staff, including providing training, scheduling, and performance oversight.

Requirements

• Minimum 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.
• Ability to handle confidential information with discretion.

Nice To Haves

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

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, including 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed