Medical Records Director

Overview

The Medical Records Director leads the management and protection of resident healthcare documentation, ensuring accuracy and compliance with all applicable federal, state, and institutional requirements. This position is vital in facilitating complete and timely record-keeping that supports clinical care and administrative operations, while safeguarding sensitive patient information within a skilled nursing facility environment.

Key Responsibilities

• Oversee the creation, maintenance, and secure storage of resident medical records following HIPAA and other regulatory mandates.
• Guarantee prompt and precise entry of admissions, discharges, transfers, and ongoing clinical updates into records.
• Evaluate the completion status of documentation to ensure alignment with facility policies and government regulations.
• Collaborate with nursing, therapy, and administrative personnel to fulfill documentation requirements.
• Manage medical record requests from residents, family members, legal representatives, and external healthcare providers.
• Administer electronic health record (EHR) platforms and address documentation-related technical challenges.
• Lead, train, and supervise the medical records team to promote compliance and efficiency.
• Compile reports and conduct audits for internal checks and external regulatory reviews.
• Maintain strict confidentiality and protection of all sensitive health data.
• Facilitate survey readiness and address inquiries concerning documentation from oversight bodies.

Supervisory Responsibilities

The role includes oversight of medical records personnel through training, scheduling, and performance management to ensure conformity with HIPAA, documentation standards, and facility policies.

Qualifications

• Associate or bachelor’s degree in Health Information Management preferred.
• Certification such as Registered Health Information Technician (RHIT) or equivalent preferred.
• At least two years of experience in medical records or health information management, ideally within long-term care settings.
• In-depth familiarity with HIPAA regulations, Medicare/Medicaid documentation guidelines, and skilled nursing facility requirements.
• Competency with electronic health records systems and Microsoft Office applications.
• Strong organizational capabilities, communication skills, and analytical problem-solving aptitude.
• Capability to juggle multiple priorities and adhere to deadlines.

Physical Demands

• Frequent periods of sitting, typing, and document review.
• Occasional standing, walking, and lifting up to 25 pounds.
• Ability to concentrate amid a dynamic work environment while handling confidential information discreetly.

Work Environment

The work setting typically involves low to moderate noise levels with reasonable accommodations available for persons with disabilities to perform essential duties effectively.

Equal Opportunity Employer Statement

Employment decisions are made without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any legally protected classification.