Medical Records Director-S

Role overview

The Medical Records Director is responsible for keeping resident health records accurate, secure, and up to date while following all relevant federal, state, and facility rules. This position supports both clinical and administrative teams, helps ensure documentation is completed on time, and protects the privacy and integrity of sensitive medical information in a skilled nursing environment.

Key duties

• Oversee the creation, upkeep, and filing of resident medical records in line with HIPAA and applicable regulatory standards.
• Make sure admissions, discharges, transfers, and clinical changes are documented promptly and correctly.
• Track record completion and confirm adherence to facility procedures as well as state and federal requirements.
• Work closely with nursing, therapy, and administrative staff to meet documentation needs.
• Process requests for medical records from residents, families, legal representatives, and external care providers.
• Manage the electronic health record system and resolve documentation-related issues as they arise.
• Train and oversee medical records team members when staff supervision is part of the role.
• Prepare audits and reports for both internal use and outside review.
• Protect confidentiality and ensure sensitive health data is handled securely at all times.
• Support readiness for surveys and answer documentation questions from regulatory agencies.

Supervisory scope

This position may include supervision of medical records personnel, with responsibilities such as training, scheduling, and performance monitoring to help maintain HIPAA compliance, documentation quality, and adherence to facility policy.

Qualifications

A background in Health Information Management is preferred, along with familiarity with skilled nursing or long-term care documentation standards. The role calls for strong organization, communication, and problem-solving skills, as well as the ability to balance multiple priorities and deadlines in a fast-paced setting.

Education and experience

• An associate’s or bachelor’s degree in Health Information Management is preferred.
• RHIT certification or a comparable credential is preferred.
• At least 2 years of experience in medical records or health information management, ideally in long-term care, is preferred.
• Working knowledge of HIPAA, Medicare/Medicaid documentation rules, and skilled nursing facility regulations is required.
• Comfort using EHR platforms and Microsoft Office is expected.

Physical requirements

• Frequent seated work, typing, and document review are part of the job.
• Occasional walking, standing, and lifting up to 25 lbs may be needed.
• The role requires sustained attention in a busy setting and careful handling of confidential information.

Work environment

The workplace is typically quiet to moderately active. Reasonable accommodations may be provided to support qualified individuals with disabilities in performing the essential functions of the role.

Equal opportunity

This employer considers all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected category.