Medical Records Full Time

Essential Duties

• Manage the creation, maintenance, and storage of resident medical records in accordance with HIPAA and regulatory guidelines
• Ensure timely and accurate documentation of admissions, discharges, transfers, and clinical updates
• Monitor record completion and compliance with facility policies and state/federal requirements
• Cook with nursing, therapy, and administrative teams to support documentation needs
• Handle requests for medical records from residents, families, legal representatives, and outside providers
• Oversee electronic health record (EHR) systems and troubleshoot documentation issues
• Train and supervise medical records staff (if applicable)
• Prepare reports and audits for internal and external review
• Maintain confidentiality and safeguard sensitive health information
• Support survey readiness and respond to documentation-related inquiries from regulatory agencies

Qualification

• Education and/or Experience: Associate or bachelor’s degree in Health Information Management preferred; Certification as a Registered Health Information Technician (RHIT) or similar credential preferred; Minimum 2 years of experience in medical records or health information management, preferably in long-term care; Strong knowledge of HIPAA, Medicare/Medicaid documentation standards, and SNF regulations; Proficiency in EHR systems and Microsoft Office; Excellent organizational, communication, and problem-solving skills; Ability to manage multiple priorities and meet deadlines