Medical Records

General Purpose

The Medical Records Director oversees the management security and accuracy of resident health records in compliance with federal state and facility regulations. This role ensures timely documentation supports clinical and administrative staff and maintains confidentiality and integrity of all medical information within the skilled nursing facility.

Essential Duties

• 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/federal requirements
• Coordinate with nursing therapy and administrative teams to support documentation needs
• Handle requests for medical records 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)
• 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

Supervisory Requirements

The Medical Records Director may supervise medical records staff providing training scheduling and performance oversight to ensure compliance with HIPAA documentation standards and facility policies.

Qualification

Education and/or Experience

• Associate or bachelors degree in Health Information Management preferred
• Certification as a Registered Health Information Technician (RHIT) or similar credential preferred
• 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 SNF regulations
• Proficiency in EHR systems and Microsoft Office
• Excellent organizational communication and problem-solving skills
• Ability to manage multiple priorities and meet deadlines

Physical Demands

• 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

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually low to moderate.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin age disability protected veteran status or any other legally protected status.