Medical Records Director

Oakwood Gardens Care Center is seeking an experienced, organized, and highly detail-oriented Full-Time Medical Records Director to oversee the accuracy, security, and regulatory compliance of our residents' medical records.

The ideal candidate will have experience in skilled nursing or long-term care medical records, strong knowledge of HIPAA requirements, and the ability to collaborate effectively with nursing, therapy, physicians, administration, and other departments.

• Organize, maintain, and oversee resident medical records in accordance with federal, state, and facility requirements.
• Ensure medical records are accurate, complete, confidential, and readily available to authorized individuals.
• Establish, maintain, and monitor medical-record policies, procedures, and filing systems.
• Review admission, readmission, transfer, and discharge records for accuracy and completeness.
• Audit resident charts regularly to identify missing signatures, incomplete documentation, outdated orders, and other deficiencies.
• Maintain systems for tracking and obtaining incomplete or delinquent documentation.
• Coordinate with physicians, licensed nurses, therapy staff, and department leaders to resolve documentation deficiencies promptly.
• Process physician orders, reports, diagnostic results, consultations, and other documentation according to established procedures.
• Assist with ICD-10 coding and diagnostic information as permitted by facility policy and individual qualifications.
• Maintain accurate resident census, admission, discharge, and transfer information.
• Prepare records for facility surveys, audits, legal requests, insurance reviews, and other authorized purposes.
• Respond to requests for medical records and protected health information in accordance with HIPAA and facility policies.
• Obtain proper authorization before releasing resident information.
• Maintain logs for record requests, disclosures, chart locations, and other required tracking.
• Safeguard electronic and paper medical records from unauthorized access, loss, alteration, or destruction.
• Follow established record-retention, storage, archiving, and destruction requirements.
• Support quality-assurance and performance-improvement activities related to documentation and medical records.
• Participate in facility meetings, audits, surveys, and regulatory inspections as requested.
• Assist department leaders with documentation education and compliance.
• Maintain resident privacy and immediately report suspected or known confidentiality violations.
• Communicate professionally with residents, families, physicians, staff, government representatives, and outside organizations.
• Perform additional duties as assigned by the Administrator or facility leadership.

• High school diploma or GED required.
• Previous medical-records experience in a skilled nursing or long-term care facility strongly preferred.
• Knowledge of HIPAA, resident confidentiality, medical terminology, and health-information management practices.
• Familiarity with federal and California requirements governing skilled nursing medical records preferred.
• Experience with Point Click Care  or another electronic health-record system preferred.
• Knowledge of ICD-10 coding and Medicare documentation requirements is helpful.
• RHIT, RHIA, or related health-information certification is preferred but not required.
• Strong computer skills, including proficiency with Microsoft Office.
• Excellent organizational, analytical, and time-management abilities.
• Exceptional attention to detail and commitment to accuracy.
• Ability to prioritize multiple…