Medical Records Directror

Responsibilities

• Manage the creation, maintenance, storage, and archiving of resident medical records.
• Ensure timely and accurate documentation of admissions, discharges, transfers, and clinical updates.
• Monitor chart completion and documentation compliance with federal, state, and facility requirements.
• Maintain HIPAA compliance and safeguard confidential resident information.
• Process and fulfill medical record requests from residents, families, legal representatives, and healthcare providers.
• Oversee electronic health record (EHR) systems and assist with documentation-related troubleshooting.
• Collaborate with nursing, therapy, social services, and administrative teams to support documentation needs.
• Prepare reports, audits, and records for internal reviews and regulatory surveys.
• Support survey readiness and respond to inquiries from state and federal agencies.
• Train and support medical records staff as needed.

Qualifications

• Minimum 2 years of medical records or health information management experience, preferably in a skilled nursing facility, post-acute care, or long-term care setting.
• Strong knowledge of HIPAA regulations, Medicare/Medicaid documentation requirements, and healthcare compliance standards.
• Experience with Electronic Health Records (EHR) systems.
• Proficiency with Microsoft Office applications.
• Excellent organizational, communication, and problem-solving skills.
• Ability to manage multiple priorities and meet deadlines in a fast-paced healthcare environment.

Preferred Qualifications

• Associate's or Bachelor's degree in Health Information Management or related field.
• RHIT, RHIA, or similar health information credential.
• Previous supervisory or leadership experience.