Medical Records Director

Role Summary

The Medical Records Director is responsible for leading the organization, protection, and accuracy of resident health records in a skilled nursing setting. The position ensures documentation is completed on time, keeps information confidential, and supports both clinical and administrative teams while staying aligned with federal, state, and facility rules.

Key Responsibilities

• Oversee the creation, upkeep, and secure retention of resident medical files in line with HIPAA and applicable regulations.
• Make sure admissions, discharges, transfers, and clinical changes are documented accurately and without delay.
• Track record completion and verify adherence to facility procedures as well as state and federal requirements.
• Work closely with nursing, therapy, and administrative departments to meet documentation needs.
• Process medical records requests from residents, family members, legal representatives, and external healthcare providers.
• Administer electronic health record systems and resolve issues related to documentation workflows.
• Train and oversee medical records personnel when the role includes direct supervision.
• Compile reports and audit materials for both internal checks and outside reviews.
• Protect sensitive health data and maintain strict confidentiality at all times.
• Support survey preparation and address documentation questions from regulators.

Qualifications

• An associate’s or bachelor’s degree in Health Information Management is preferred.
• RHIT certification, or an equivalent credential, is preferred.
• At least 2 years of experience in medical records or health information management, ideally in long-term care.
• Working knowledge of HIPAA, Medicare/Medicaid documentation rules, and skilled nursing facility regulations.
• Comfort using EHR platforms and Microsoft Office tools.
• Strong ability to organize work, communicate clearly, and solve problems effectively.
• Capacity to handle several priorities at once and meet deadlines consistently.

Supervisory Scope

This role may involve supervising medical records staff, including providing training, setting schedules, and reviewing performance to ensure HIPAA compliance, documentation quality, and adherence to facility policies.

Physical Requirements

• Regularly involves sitting for long periods, typing, and reviewing records.
• Sometimes requires walking, standing, and lifting items up to 25 lbs.
• Must be able to stay focused in a busy setting and handle confidential information carefully.

Work Environment

The job is performed in an environment where the noise level is generally low to moderate. Reasonable accommodations may be provided to support individuals with disabilities in performing the essential duties.

Equal Opportunity Statement

All qualified applicants are considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.

Compensation

The annual salary range for this position is $65,000 to $75,000.