What are the responsibilities and job description for the Medical Records position at Peninsula Post Acute?
General Purpose
The Medical Records oversees the management, security, and accuracy of resident health records in compliance with federal, state, and facility regulations. This role ensures timely documentation, supports clinical and administrative staff, and maintains confidentiality and integrity of all medical information within the skilled nursing facility.
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
Coordinate 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
Physical Demands
Frequent sitting, typing, and reviewing documents
Occasional walking, standing, and lifting up to 25 lbs
Ability to focus in a busy environment and handle confidential information with discretion
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually low to moderate.
