Medical Records Consultant

Job Title: Medical Records Consultant

Job Type: Full-Time Reports To: Vice President of Operations

Job Summary:

We are seeking an experienced and detail-oriented Medical Records Consultant to oversee, audit, and ensure compliance of medical records across multiple skilled nursing facilities in California. The ideal candidate will bring expertise in clinical documentation standards, state and federal regulations (including Title 22 and OBRA), HIPAA compliance, and electronic health record (EHR) systems. This role plays a critical part in supporting regulatory readiness, quality assurance, and proper documentation practices within the facilities. The position also involves providing ongoing support and education to multiple facilities and their medical records departments, requiring regular travel between sites.

Qualifications:

• Education: Associate or Bachelor’s degree in Health Information Management, Nursing, or related healthcare field preferred.
• Certification: RHIT, RHIA, or other relevant credential (preferred but not required).
• Experience: Minimum of 2-3 years of experience in medical records management or consulting within a Skilled Nursing Facility (SNF) or long-term care environment.
• Strong knowledge of Title 22 California Code of Regulations, OBRA, and CMS guidelines.
• Familiarity with EMR/EHR systems (e.g., PointClickCare, MatrixCare, or similar).
• Strong analytical, organizational, and communication skills.
• Ability to work independently and collaboratively with clinical and administrative teams.
• Willingness and ability to travel regularly between assigned facilities.
  
  
  

Key Responsibilities:

• Review and audit resident medical records for accuracy, completeness, and compliance with CDPH, CMS, Title 22, and HIPAA regulations.
• Ensure timely and accurate documentation of admissions, transfers, discharges, and resident care in accordance with facility policies and federal/state guidelines.
• Provide consultation, training, and ongoing education to multiple facilities and their medical records departments on proper documentation standards, including progress notes, care plans, MDS documentation, and physician orders.
• Monitor and assist with maintaining accurate census data and medical record indexing.
• Collaborate with the Director of Nursing, MDS Coordinator, and interdisciplinary team to resolve documentation deficiencies.
• Assist with preparation for CDPH surveys, audits, and quality assurance reviews.
• Recommend process improvements and policy updates to strengthen the facilities’ medical records systems.
• Assist with transitioning or optimizing electronic medical records (EMR/EHR) platforms as needed.
• Ensure secure handling, retention, and disposal of protected health information (PHI) in compliance with HIPAA standards.
• Provide monthly or quarterly reports to the Vice President of Operations and facility leadership on medical records findings and corrective action plans.
• Travel to assigned facilities on a regular basis to provide on-site support, education, and oversight.
  
  
  

Schedule & Compensation:

• Flexible hours depending on facility needs
• Remote documentation review option may be available depending on facility setup