Medical Records Director

Position Overview

The Medical Records Director is responsible for overseeing the management, accuracy, and security of patient health records, ensuring adherence to federal, state, and institutional regulations. This role supports both clinical and administrative teams by facilitating timely documentation and upholding the confidentiality and integrity of medical information within a skilled nursing facility.

Key Responsibilities

• Direct the creation, maintenance, and proper storage of resident medical records, ensuring compliance with HIPAA and regulatory standards.
• Guarantee prompt and precise documentation of patient admissions, discharges, transfers, and clinical updates.
• Monitor record completion and ensure compliance with facility policies and federal/state requirements.
• Collaborate closely with nursing, therapy, and administrative personnel to fulfill documentation needs.
• Manage requests for medical records from residents, their families, legal representatives, and external healthcare providers.
• Oversee electronic health record (EHR) systems, addressing and resolving any documentation problems.
• Provide training and supervision to medical records staff when applicable.
• Compile reports and conduct audits for both internal purposes and external reviews.
• Maintain strict confidentiality and protect sensitive health information.
• Ensure survey readiness and respond to documentation-related inquiries from regulatory bodies.

Supervisory Duties

This role may include supervising medical records personnel, including responsibilities such as training, scheduling, and performance management to ensure HIPAA compliance and adherence to documentation standards.

Qualifications and Experience

• Associate or bachelor's degree in Health Information Management is preferred.
• Certification as a Registered Health Information Technician (RHIT) or a related credential is advantageous.
• At least two years of experience in medical records or health information management, ideally within long-term care settings.
• Thorough understanding of HIPAA regulations, Medicare/Medicaid documentation standards, and skilled nursing facility (SNF) requirements.
• Proficiency with electronic health record systems and Microsoft Office applications.
• Strong organizational, communication, and problem-solving abilities.
• Capability to handle multiple tasks efficiently and meet strict deadlines.

Physical Requirements

• Frequent sitting with extensive typing and document review.
• Intermittent walking, standing, and occasional lifting up to 25 pounds.
• Ability to maintain focus in a busy environment while handling sensitive information with discretion.

Work Environment and Equal Opportunity

The typical work environment involves noise levels ranging from low to moderate. Reasonable accommodations are available for individuals with disabilities to perform essential job functions. This employer is committed to equal opportunity and welcomes applications without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected status.