Medical Records

Castle Hills Rehabilitation and Care Center; San Antonio (TX); On-site; USD 55,000 - 85,000; Full time

Job summary

Castle Hills Rehabilitation and Care Center in San Antonio, TX seeks a Medical Records Director to oversee the management, security, and accuracy of resident health records in accordance with HIPAA and regulatory guidelines.

You will coordinate with nursing, therapy, and administrative teams, supervise records staff, and prepare reports and audits while ensuring timely documentation of admissions, transfers, and discharges.

Qualifications

• Associate or bachelor’s degree in Health Information Management.
• RHIT certification preferred.
• Minimum 2 years of medical records experience, preferably in long-term care.
• Strong knowledge of HIPAA, Medicare/Medicaid documentation standards, and SNF regulations.
• Proficient in EHR systems and Microsoft Office.

Responsibilities

• Oversee creation, maintenance, and storage of resident medical records per regulatory guidelines.
• Ensure timely and accurate documentation of admissions, discharges, transfers, and clinical updates.
• Coordinate with nursing, therapy, and administrative teams to support documentation needs.
• Train and supervise medical records staff, if applicable.
• Prepare reports and audits for internal and external review; support survey readiness.

Skills

HIPAA knowledge

EHR proficiency

Microsoft Office

Education

Associate or Bachelor’s in Health Information Management

RHIT certification preferred

Tools

EHR systems

Job description

General PurposeThe 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.Essential DutiesManage the creation, maintenance, and storage of resident medical records in accordance with HIPAA and regulatory guidelinesEnsure timely and accurate documentation of admissions, discharges, transfers, and clinical updatesMonitor record completion and compliance with facility policies and state/federal requirementsCoordinate with nursing, therapy, and administrative teams to support documentation needsHandle requests for medical records from residents, families, legal representatives, and outside providersOversee electronic health record (EHR) systems and troubleshoot documentation issuesTrain and supervise medical records staff (if applicable)Prepare reports and audits for internal and external reviewMaintain confidentiality and safeguard sensitive health informationSupport survey readiness and respond to documentation-related inquiries from regulatory agenciesSupervisory RequirementsThe Medical Records Director may supervise medical records staff, providing training, scheduling, and performance oversight to ensure compliance with HIPAA, documentation standards, and facility policies.QualificationEducation and/or ExperienceAssociate or bachelor’s degree in Health Information Management preferredCertification as a Registered Health Information Technician (RHIT) or similar credential preferredMinimum 2 years of experience in medical records or health information management, preferably in long-term careStrong knowledge of HIPAA, Medicare/Medicaid documentation standards, and SNF regulationsProficiency in EHR systems and Microsoft OfficeExcellent organizational, communication, and problem-solving skillsAbility to manage multiple priorities and meet deadlinesPhysical DemandsFrequent sitting, typing, and reviewing documentsOccasional walking, standing, and lifting up to 25 lbsAbility to focus in a busy environment and handle confidential information with discretionWork EnvironmentThe 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.