Medical Records Director

Sweetwater Care; Clearlake (CA); On-site; USD 90,000 - 130,000; Full time

Benefits offered by this job

Competitive compensation

Professional growth

Supportive team

Job summary

Meadowood Nursing Center seeks a Medical Records Director (HIM) to oversee the accurate, timely, and confidential management of resident health information in line with California state regulations and federal requirements.

You will support clinical operations, survey readiness, and the integrity of health records across the facility, ensuring confidentiality and compliance while collaborating with an interdisciplinary team.

Qualifications

• High school diploma or equivalent required; post-secondary education or HIM coursework preferred.
• Minimum 1 year of experience in skilled nursing or long-term care setting preferred.
• Proficiency in electronic health record (EHR) systems and Microsoft Office applications.
• Strong organizational skills, attention to detail, and ability to meet regulatory deadlines.
• Excellent verbal and written communication skills.
• Ability to work independently and as part of a multidisciplinary team.

Responsibilities

• Maintain, organize, and secure active and inactive medical records in compliance with CA, CMS regulations, and facility policies.
• Review medical charts for accuracy and completeness; follow up with nursing and ancillary staff to resolve deficiencies within required timeframes
• Ensure documentation meets California Regulations and survey readiness standards at all times
• Coordinate the release of health information in accordance with HIPAA, California privacy laws, and facility authorization procedures.
• Prepare and maintain reports, logs, and other required documentation for California inspections, state and federal surveys, and internal audits.
• Manage record retention and destruction according to California state retention schedules and facility procedures.
• Provide timely and accurate health information to interdisciplinary team members to support resident care and clinical decision-making.
• Participate in Quality Assurance and Performance Improvement (QAPI) initiatives related to documentation and record accuracy.
• Maintain strict confidentiality and comply with all privacy and security regulations.

Skills

EHR experience

Regulatory knowledge

Communication skills

Multidisciplinary teamwork

Education

High school diploma or equivalent

HIM coursework preferred

Tools

Electronic Health Record (EHR) systems

Microsoft Office

Job description

At Meadowood Nursing Center, we believe in creating a supportive, compassionate, and collaborative environment where both our residents and team members can thrive. Our community is proud to have a dedicated team with many long-tenured staff members who bring exceptional experience and heart to the work we do each day.

Rooted in integrity, respect, teamwork, and a commitment to excellence, we take pride in providing high-quality care while fostering a workplace where employees feel valued and supported.

If you're looking to build a meaningful career in a stable and mission-driven organization, we invite you to join our team!

The Medical Records Director (HIM) position is a new addition to the team and is responsible for the accurate, timely, and confidential maintenance of resident health information and medical records in accordance with California state regulations and guidelines, federal requirements, and facility policies.

This position plays a vital role in supporting clinical operations, survey readiness, and ensuring the integrity of resident health information within our skilled nursing facility.

Essential Duties and Responsibilities:

• Maintain, organize, and secure active and inactive medical records in compliance with CA, CMS regulations, and facility policies.

• Review medical charts for accuracy and completeness; follow up with nursing and ancillary staff to resolve deficiencies within required timeframes

• Ensure documentation meets California Regulations and survey readiness standards at all times

• Coordinate the release of health information in accordance with HIPAA, California privacy laws, and facility authorization procedures.

• Prepare and maintain reports, logs, and other required documentation for California inspections, state and federal surveys, and internal audits.

• Manage record retention and destruction according to California state retention schedules and facility procedures.

• Provide timely and accurate health information to interdisciplinary team members to support resident care and clinical decision-making.

• Participate in Quality Assurance and Performance Improvement (QAPI) initiatives related to documentation and record accuracy.

• Maintain strict confidentiality and comply with all privacy and security regulations.

Qualifications:

• High school diploma or equivalent required; post-secondary education or HIM coursework preferred.

• Minimum of 1 year of experience in a skilled nursing or long-term care setting preferred

• Proficiency in electronic health record (EHR) systems and Microsoft Office applications

• Strong organizational skills, attention to detail, and ability to meet regulatory deadlines.

• Excellent verbal and written communication skills

• Ability to work independently and as part of a multidisciplinary team.

Benefits:

• Competitive compensation and comprehensive benefits package

• Opportunities for professional growth and advancement

• Supportive team environment with a focus on regulatory excellence and resident care.