Medical Records Director

PACS•Richardson Nursing and Rehabilitation, NE

23h

About The Position

The Medical Records Director oversees the management, security, and accuracy of resident health records in compliance with federal, state, and facility regulations. The role ensures timely documentation, supports clinical and administrative staff, and maintains the confidentiality and integrity of medical information within a skilled nursing facility. The position manages resident medical records and the facility’s electronic health record systems, coordinates documentation needs with clinical and administrative teams, handles medical-record requests, and prepares reports and audits. It also supports survey readiness and responds to documentation-related inquiries from regulatory agencies. The director may train and supervise medical records staff, including providing scheduling and performance oversight.

Requirements

Minimum 2 years of experience in medical records or health information management; preferably in long-term care.
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.
Frequent sitting, typing, and reviewing documents; occasional walking, standing, and lifting up to 25 lbs.
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 preferred.
Certification as a Registered Health Information Technician (RHIT) or similar credential 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 training, 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.