Medical Records

Memorial Medical Nursing and Rehabilitation; San Antonio (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Memorial Medical Nursing and Rehabilitation is seeking a Medical Records Director to oversee the management, security, and accuracy of resident health records in a HIPAA-compliant skilled nursing setting. You will lead documentation efforts for admissions, discharges, transfers, and updates while supporting clinical and administrative staff.

The role requires a Health Information Management degree (RHIT preferred) and at least 2 years in medical records within long-term care, with strong

Qualifications

• Associate or bachelor’s degree in Health Information Management preferred.
• 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.

Responsibilities

• Oversee creation, maintenance, and storage of resident medical records per HIPAA and regulations.
• Ensure timely and accurate documentation of admissions, discharges, transfers, and clinical updates.
• Monitor record completion and compliance with 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.
• Train and supervise medical records staff and prepare reports for audits.

Skills

HIPAA knowledge

EHR proficiency

Regulatory knowledge

Microsoft Office

Education

Health Information Management degree

RHIT certification preferred

Tools

EHR systems

Microsoft Office

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.