Job Description

Position Summary

The  Medical Records Director oversees the organization, maintenance, and protection of all resident health records in compliance with federal and state regulations, HIPAA requirements, and facility policies. This position plays a vital role in ensuring documentation integrity, supporting clinical staff, and facilitating audits, billing, and legal documentation needs.

Essential Duties and Responsibilities

• Organize and maintain accurate, complete, and confidential medical records for all residents.
• Ensure compliance with HIPAA and other federal/state laws regarding patient information.
• Oversee timely completion and filing of admission documentation, progress notes, physician orders, care plans, and discharge summaries.
• Monitor and audit medical records for completeness, accuracy, and compliance with documentation standards.
• Assist in preparation for state surveys and external audits (Medicare, Medicaid, etc.).
• Track, manage, and ensure timely physician signatures and documentation updates.
• Manage release of information (ROI) requests, ensuring proper authorization and confidentiality.
• Coordinate archiving and proper disposal of inactive or expired records per regulations.
• Work collaboratively with interdisciplinary teams, including nursing, therapy, billing, and administration.
• Train and support staff on documentation best practices and record-keeping protocols.

Knowledge, Skills and Abilities

• Strong understanding of HIPAA, CMS documentation requirements, and electronic health record (EHR) systems (e.g., PointClickCare, MatrixCare).
• Excellent organizational skills, attention to detail, and ability to manage multiple priorities. Proficient in computer and data entry skills.
• Familiarity with quality measures and healthcare reporting requirements (Preferred)

Education & Experience

• High School Diploma or GED required; Associate degree or certification in Health Information Management preferred.
• Minimum 1–2 years in medical records management, preferably in a long-term care or SNF setting.
• RHIT (Registered Health Information Technician) or related certification. (Preferred)
• Experience with MDS documentation and survey readiness processes. (Preferred)

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