Medical Records Director

PACS•Wilmington, DE

7d•Onsite

About The Position

St. Francis Healthcare Center is seeking an organized, detail-oriented, and experienced Medical Records Director to oversee the facility's medical records and health information management operations. The Medical Records Director will be responsible for maintaining accurate, complete, confidential, and compliant resident records while ensuring documentation meets facility, state, and federal requirements. This position works closely with clinical leadership, nursing, admissions, billing, and other departments to support quality resident care and regulatory compliance.

Requirements

Previous experience in medical records, health information management, or a healthcare documentation role.
Strong knowledge of medical record documentation requirements and HIPAA regulations.
Excellent organizational and time-management skills.
Strong attention to detail and accuracy.
Excellent written and verbal communication skills.
Ability to maintain confidentiality and handle sensitive information professionally.
Proficiency with electronic medical records (EMR) systems and Microsoft Office.
Ability to work independently while collaborating effectively with an interdisciplinary team.

Nice To Haves

Experience in a skilled nursing facility (SNF) or long-term care setting preferred.
Prior supervisory or management experience preferred.

Responsibilities

Direct and oversee the daily operations of the Medical Records/Health Information Management department.
Maintain accurate, complete, and timely resident medical records.
Ensure medical records comply with federal, state, and facility requirements.
Review records for completeness, accuracy, and appropriate documentation.
Coordinate medical record management for admissions, discharges, and transfers.
Maintain organized electronic and paper medical records as applicable.
Monitor physician orders, progress notes, nursing documentation, and other required clinical records for completion.
Coordinate with nursing and interdisciplinary teams to resolve documentation deficiencies.
Prepare medical records and documentation for audits, surveys, and regulatory reviews.
Maintain strict confidentiality of resident health information and follow HIPAA requirements.
Manage requests for medical records in accordance with applicable regulations and facility policies.
Track and follow up on outstanding documentation and signatures.
Assist with medical record audits and quality assurance activities.
Develop and maintain effective department policies and procedures.
Train and educate staff regarding medical records, documentation standards, and confidentiality.
Work collaboratively with the Administrator, Director of Nursing, MDS, Social Services, Admissions, and other departments.
Ensure proper retention, storage, and disposal of medical records.
Participate in Quality Assurance and Performance Improvement (QAPI) initiatives as appropriate.