Medical Records Director Full-Time

PACS•Fresno, CA

7d•$20 - $25•Onsite

About The Position

Oakwood Gardens Care Center is seeking an experienced, organized, and highly detail-oriented Full-Time Medical Records Director to oversee the accuracy, security, and regulatory compliance of our residents’ medical records. The ideal candidate will have experience in skilled nursing or long-term care medical records, strong knowledge of HIPAA requirements, and the ability to collaborate effectively with nursing, therapy, physicians, administration, and other departments.

Requirements

High school diploma or GED required.
Knowledge of HIPAA, resident confidentiality, medical terminology, and health-information management practices.
Strong computer skills, including proficiency with Microsoft Office.
Excellent organizational, analytical, and time-management abilities.
Exceptional attention to detail and commitment to accuracy.
Ability to prioritize multiple responsibilities and meet established deadlines.
Strong written and verbal communication skills.
Ability to maintain professionalism and confidentiality at all times.

Nice To Haves

Previous medical-records experience in a skilled nursing or long-term care facility strongly preferred.
Familiarity with federal and California requirements governing skilled nursing medical records preferred.
Experience with PointClickCare or another electronic health-record system preferred.
Knowledge of ICD-10 coding and Medicare documentation requirements is helpful.
RHIT, RHIA, or related health-information certification is preferred but not required.

Responsibilities

Organize, maintain, and oversee resident medical records in accordance with federal, state, and facility requirements.
Ensure medical records are accurate, complete, confidential, and readily available to authorized individuals.
Establish, maintain, and monitor medical-record policies, procedures, and filing systems.
Review admission, readmission, transfer, and discharge records for accuracy and completeness.
Audit resident charts regularly to identify missing signatures, incomplete documentation, outdated orders, and other deficiencies.
Maintain systems for tracking and obtaining incomplete or delinquent documentation.
Coordinate with physicians, licensed nurses, therapy staff, and department leaders to resolve documentation deficiencies promptly.
Process physician orders, reports, diagnostic results, consultations, and other documentation according to established procedures.
Assist with ICD-10 coding and diagnostic information as permitted by facility policy and individual qualifications.
Maintain accurate resident census, admission, discharge, and transfer information.
Prepare records for facility surveys, audits, legal requests, insurance reviews, and other authorized purposes.
Respond to requests for medical records and protected health information in accordance with HIPAA and facility policies.
Obtain proper authorization before releasing resident information.
Maintain logs for record requests, disclosures, chart locations, and other required tracking.
Safeguard electronic and paper medical records from unauthorized access, loss, alteration, or destruction.
Follow established record-retention, storage, archiving, and destruction requirements.
Support quality-assurance and performance-improvement activities related to documentation and medical records.
Participate in facility meetings, audits, surveys, and regulatory inspections as requested.
Assist department leaders with documentation education and compliance.
Maintain resident privacy and immediately report suspected or known confidentiality violations.
Communicate professionally with residents, families, physicians, staff, government representatives, and outside organizations.
Perform additional duties as assigned by the Administrator or facility leadership.