Medical Records Director

Job Title: Medical Records Director
Location: Channel Islands Post Acute
Position Type: Full-Time
Salary: $72,000 – $80,000 annually

Position Summary:
The Medical Records Director is responsible for overseeing and managing all aspects of the medical records department within a skilled nursing facility. This role ensures the accurate collection, maintenance, storage, and confidentiality of resident medical records in accordance with federal, state, and facility regulations. The Medical Records Director works closely with nursing leadership, administration, and interdisciplinary teams to support clinical operations, regulatory compliance, and quality resident care.

Key Responsibilities:

• Manage and oversee the day-to-day operations of the Medical Records Department.
• Ensure resident medical records are complete, accurate, and maintained in compliance with state and federal regulations, including HIPAA guidelines.
• Maintain secure systems for storing and retrieving medical records, both electronic and paper-based.
• Monitor medical record documentation for completeness, accuracy, and timeliness.
• Coordinate with nursing staff, physicians, and interdisciplinary team members to ensure proper documentation of resident care.
• Conduct regular chart audits and follow up with staff to correct missing or incomplete documentation.
• Prepare medical records for admissions, transfers, and discharges.
• Maintain and organize active and archived medical records according to regulatory retention requirements.
• Respond to requests for medical records from physicians, hospitals, families, and authorized agencies while ensuring confidentiality requirements are met.
• Support facility surveys and regulatory inspections by ensuring records are organized and compliant.
• Assist leadership with quality assurance and performance improvement initiatives related to documentation.
• Provide guidance and education to staff regarding proper documentation procedures and medical record compliance.
• Ensure timely completion and filing of physician orders, progress notes, care plans, and other clinical documentation.

Qualifications:

• Previous experience in medical records within a skilled nursing facility or healthcare setting preferred.
• Strong knowledge of medical terminology and healthcare documentation practices.
• Familiarity with electronic health record (EHR) systems.
• Understanding of HIPAA regulations and confidentiality standards.
• Excellent organizational, communication, and problem-solving skills.
• Ability to manage multiple tasks while maintaining attention to detail.
• High school diploma or equivalent required; additional training in Health Information Management or related field preferred.

Work Environment:
This position works closely with nursing leadership, administration, and clinical staff to support efficient facility operations and ensure compliance with healthcare regulations while maintaining accurate resident health records.

Job Type: Full-time

Pay: $72,000.00 - $80,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: In person

Salary : $72,000 - $80,000