Medical Records

SANANTONIOWEST in; San Antonio (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

SANANTONIOWEST is seeking a Medical Records Director to oversee the management, security, and accuracy of resident health records in our skilled nursing facility in San Antonio, TX. The role ensures timely documentation, supports clinical and administrative staff, and maintains confidentiality of all medical information in compliance with HIPAA, Medicare/Medicaid standards, and SNF regulations.

You will supervise records staff, coordinate with care teams, and prepare reports for audits and

Qualifications

• Bachelor's or associate degree in health information management or related field.
• RHIT or similar credential preferred.
• Minimum 2 years of experience in medical records or health information management.
• Strong knowledge of HIPAA, Medicare/Medicaid documentation standards, and SNF regulations.
• Proficiency in EHR systems and Microsoft Office.
• Excellent organizational, communication, and problem-solving abilities.
• Ability to manage multiple priorities and meet deadlines.

Responsibilities

• Create, maintain, and securely store resident medical records per HIPAA and regulations.
• Ensure timely 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 admin teams to support documentation needs.
• Handle requests for medical records from residents, families, and providers.
• Oversee EHR systems and troubleshoot documentation issues.
• Train and supervise medical records staff where applicable.
• Prepare reports and audits for internal and external review.
• Maintain confidentiality and safeguard sensitive health information.
• Support survey readiness and respond to documentation inquiries from agencies

Skills

HIPAA knowledge

Organizational skills

Communication skills

Problem-solving skills

Regulatory knowledge

Education

Health Information Management degree

RHIT certification preferred

Tools

EHR systems

Microsoft Office

Job description

The Medical Records Director 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.

• 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

Supervisory Requirements

The Medical Records Director may supervise medical records staff, providing training, scheduling, and performance oversight to ensure compliance with HIPAA, documentation standards, and facility policies.

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

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.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.