KC- Director of Medical Records

Hours of Operation

The hours will be set by the Administrator.

The Medical Records Clerk’s primary function is to compile, process, and maintain medical records of residents. Order, stock, deliver, and maintain supplies.

• Direct and maintain complete, accurate, and timely medical records for all residents
• Assemble, audit, and monitor medical records for required documentation, signatures, and physician orders
• Ensure records reflect the residents’ plan of care and support clinical decision‑making
• Maintain admission, discharge, transfer, and closed record processes

• Ensure compliance with CMS regulations, HIPAA, and state long‑term care requirements
• Prepare and organize medical records for surveys, audits, and complaint investigations
• Participate in state and federal surveys and respond to documentation requests
• Maintain documentation systems in a constant state of survey readiness

• Safeguard all protected health information (PHI)
• Process medical record requests in compliance with HIPAA and facility policy
• Maintain release‑of‑information logs and authorization forms
• Ensure proper storage, retention, and destruction of records per regulatory standards

• Oversee electronic and/or hybrid medical record systems
• Ensure accurate scanning, indexing, and maintenance of electronic records
• Collaborate with nursing, therapy, and ancillary departments to support documentation workflows
• Train staff on proper documentation standards and medical record procedures

• Conduct routine medical record audits to identify deficiencies and trends
• Report audit findings and participate in corrective action planning
• Support QAPI initiatives related to documentation accuracy and compliance
• Supervise and train medical records staff, when applicable
• Serve as a resource to interdisciplinary team members regarding documentation standards
• Collaborate with nursing leadership, physicians, and department heads to resolve documentation issues
• Process records when a resident is admitted.
• Verify diagnoses and allergies with DON/ADON and/or other designated staff and record on admission record.
• Ensure that all information is complete on admission record; place admission record in medical record; notify DON/ADON and/or other designated staff member when documentation is incomplete.
• File medical records and review for completeness, accuracy, and compliance with state and federal regulations; within 24 – 48 hours initiate audit; complete form and follow‑up with DON/ADON and/or other designated staff member within 72 hours.
• Retrieve resident medical records for physicians, other medical personnel, and facility staff.
• Protect the security of medical records to ensure confidentiality.
• Responsible for “thinning” of overflow from in‑house records and filing in discharge record order.
• Audit transfer/discharge information to ensure accuracy and completeness.
• Release information to persons or agencies according to regulations.
• Assist with processing computer forms, nursing staff, and administrative staff as assigned.
• Ensure certifications and/or recertifications for Medicare residents are signed by attending physicians.
• Purge files yearly and send them to off‑site location.
• Track physician visits and inform the DON/ADON weekly of residents who need to be seen for visits.
• Mail doctor orders and telephone orders for the campus.
• Complete chart audits assigned by DON/ADON.
• Maintain supplies and paperwork for all units.
• Obtain monthly physician orders signatures.
• Collect paperwork and time corrections from North and South units and deliver to designated staff members daily.
• Comply with federal, state, and company policies, procedures, and regulations.
• Operate computers programmed with software needed to record, store, and analyze resident information; operate copy/fax/printer machines to send documents and produce documents.
• Must be able to work any shift as directed by the Administrator.
• Please refer to the Physical and Other Requirements section for abilities…