Medical Records Director

Overview

The Medical Records Director is responsible for overseeing the management, security, and accuracy of resident health records at a skilled nursing facility, ensuring compliance with federal, state, and facility regulations. This role guarantees timely documentation, supports both clinical and administrative teams, and safeguards the confidentiality and integrity of all medical records.

Key Responsibilities

• Supervise the creation, maintenance, and storage of resident medical files adhering to HIPAA and regulatory standards.
• Ensure prompt and precise documentation of admissions, discharges, transfers, and clinical updates.
• Monitor completeness of records and enforce compliance with facility policies and government regulations.
• Collaborate with nursing, therapy, and administrative personnel to fulfill documentation requirements.
• Process requests for medical records from residents, family members, legal representatives, and external providers.
• Manage electronic health record (EHR) systems, including troubleshooting documentation issues.
• Provide training and supervision to medical records staff if applicable.
• Prepare internal and external reports and conduct audits for review.
• Maintain confidentiality and protect sensitive health information at all times.
• Support readiness for regulatory surveys and address documentation inquiries from agencies.

Supervisory Responsibilities

Possibly manages medical records staff by organizing training, scheduling, and evaluating performance to ensure adherence to HIPAA, documentation standards, and facility policies.

Qualifications

• Associate or bachelor's degree in Health Information Management is preferred.
• Certification as a Registered Health Information Technician (RHIT) or equivalent credential is desirable.
• At least 2 years of experience in medical records or health information management, ideally within long-term care.
• Comprehensive knowledge of HIPAA, Medicare/Medicaid documentation rules, and skilled nursing facility regulations.
• Proficient with EHR software and Microsoft Office suite.
• Strong organizational, communication, and problem-solving capabilities.
• Capacity to multitask and meet deadlines effectively.

Physical Requirements

• Frequent periods spent sitting, typing, and reviewing documentation.
• Occasional walking, standing, and ability to lift items weighing up to 25 pounds.
• Ability to maintain focus in a dynamic work setting while handling confidential data discreetly.

Work Environment

The working conditions typically include a low to moderate noise level environment. Reasonable accommodations will be provided to support employees with disabilities in fulfilling essential job functions.

Equal Employment Opportunity

The employer is an equal opportunity provider, offering employment consideration regardless of race, color, religion, gender, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected classification.