Medical Records Director
About The Position
Canyon Springs Post Acute is seeking an experienced, detail-oriented Medical Records Director to oversee its medical records department and ensure resident health information is accurate, secure, confidential, and compliant with HIPAA and applicable state and federal regulations. The role manages records from creation and organization through storage, retrieval, retention, and authorized release, while supporting facility survey readiness and regulatory reviews. The director works with nursing, rehabilitation, administrative teams, facility leadership, and medical records staff to maintain timely, complete documentation and improve departmental operations. The position also oversees electronic health record systems, conducts audits, manages records requests, and provides staff training and guidance on documentation standards and compliance.
Requirements
- Previous medical records experience.
- At least 2 years of experience in medical records or health information management.
- Strong knowledge of HIPAA, Medicare/Medicaid documentation standards, and skilled nursing facility regulations.
- Experience working with electronic health record systems and Microsoft Office.
- Excellent organizational, communication, leadership, and problem-solving skills.
- Ability to manage multiple priorities, meet deadlines, and maintain accuracy in a fast-paced healthcare environment.
- Demonstrated commitment to confidentiality, regulatory compliance, and quality documentation.
Nice To Haves
- Skilled nursing or long-term care experience.
- Associate or bachelor's degree in Health Information Management.
- RHIT certification or a similar health information management credential.
Responsibilities
- Oversee the creation, organization, maintenance, storage, and retrieval of resident medical records in compliance with HIPAA and applicable state and federal regulations.
- Ensure timely and accurate documentation of resident admissions, discharges, transfers, and clinical updates.
- Monitor records for completeness, accuracy, and compliance with facility policies and regulatory requirements.
- Coordinate with nursing, rehabilitation, and administrative departments to ensure documentation is accurate and completed on time.
- Manage medical-record requests from residents, families, legal representatives, healthcare providers, and authorized agencies.
- Oversee electronic health record systems and resolve documentation issues.
- Conduct routine medical-records audits and prepare reports for internal reviews, external audits, and regulatory inspections.
- Maintain confidentiality and safeguard protected health information.
- Support facility survey readiness and respond to documentation-related inquiries from regulatory agencies.
- Develop, implement, and maintain medical-records policies and procedures.
- Identify opportunities to improve documentation accuracy, workflow efficiency, and regulatory compliance.
- Ensure records are properly indexed, filed, retained, and released according to established policies.
- Supervise and support medical records staff, as applicable.
- Train and guide staff on documentation standards, confidentiality, and regulatory compliance.
- Coordinate staffing schedules and monitor departmental performance.
- Set expectations for accuracy, timeliness, and adherence to facility policies.
- Collaborate with facility leadership to address documentation concerns and improve departmental operations.
Benefits
- Competitive benefits package
- Opportunity to contribute to quality resident care and regulatory compliance
- Collaborative healthcare team environment
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
