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 clinical and administrative staff while protecting the confidentiality and integrity of medical information. The position manages resident records and related documentation, handles medical-record requests, oversees electronic health record systems, and prepares reports and audits for review. It also supports survey readiness and may supervise medical records staff through training, scheduling, and performance oversight.
Requirements
- Minimum 2 years of experience in medical records or health information management.
- 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 focus in a busy environment and handle confidential information with discretion.
Nice To Haves
- Associate or bachelor’s degree in Health Information Management.
- Registered Health Information Technician (RHIT) certification 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, including providing 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.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
