Medical Records Director

Thespringspostacute; Norwalk (CA); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Paid sick leave

PTO

Vision

401(k)

Life insurance

Job summary

The Springs Post-Acute is seeking a Medical Records Director to oversee records management for a 99-bed skilled nursing facility and rehabilitation setting.

You will ensure complete, accessible health records compliant with laws and facility policies while leading audits and maintaining confidentiality. This role requires strong clerical skills, EMR familiarity, and meticulous data handling. Join a supportive team with competitive pay and benefits.

Qualifications

• Education: High School graduate or equivalent.
• License: None Required.
• Work Experience: At least one year of clerical experience, including filing.
• Experience as a medical records practitioner in long term care facility preferred.
• Ability to type, calculate and perform data entry skills.

Responsibilities

• Perform health record maintenance duties; assembling, labeling, filing and purging documents.
• Keys information into computer systems, including EMR.
• Maintain stock of forms and record supplies.
• Request necessary resident information from transferring facilities.
• Process external information requests from authorized institutions and individuals.
• Compile statistical data at the direction of Administrator.
• Prepare Alirts (OSHPD) yearly report.
• Maintain the confidentiality and physical security of health records in accordance with HIPPA rules and regulations.
• Perform concurrent and discharge quantitative audits of health records.

Skills

Typing

Data entry

Organizational skills

Communication

Education

High School diploma

Tools

EMR software

Job description

Salary Range: $60,000.00 To $80,000.00 Annually

Join our dedicated healthcare team as a Medical Records Directorand make a meaningful impact by providing compassionate care to those in need.

The Springs Post-Acute is a 99-bed Skilled Nursing Facility with a Post-Acute Rehabilitation setting. Our exceptional care ranges from Wound Care to Occupational, Speech and Physical Therapy. Our leadership is very supportive with a welcoming environment.

WHY JOIN US?

At The Springs Post-Acute, we offer more than just a job—we provide a supportive environment where you can grow both professionally and personally. We prioritize your well-being with competitive pay, flexible schedules, and comprehensive benefits, while fostering a culture of teamwork, respect, and continuous learning. If you're passionate about making a difference in patients' lives and want to be part of a caring, dynamic team, we’d love for you to join us!

Overview of the position:

The Medical Records Supervisor assumes authority, responsibility and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards and county, state and federal laws and regulations, as applicable, for long term care facilities. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized.

Essential Job Functions:

Perform health record maintenance duties; assembling, labeling, cleaning, filing and purging documents

Keys information into computer systems, including EMR

Maintain stock of forms and record supplies

Request necessary resident information from transferring facilities

Process external information requests from authorized institutions and individuals

Compile statistical data at the direction of Administrator

Prepare Alirts (OSHPD) yearly report

Maintain the confidentiality and physical security of health records in accordance with HIPPA rules and regulationS

Perform concurrent and discharge quantitative audits of health records. Physician visit audits. Notification of physician when required by procedure

Develop and perform specialized audits on a predetermined time sequenced rotation with plan of completion to be defined and time limited. Audit all current resident charts to notate deficiencies and obtain and assist in corrections on a scheduled basis. Submit deficiency reports and to persons responsible for correction with date of completion to be returned (3 days) to the Administrator, Director of Nurses or designated representatives.

• Disease index coding at time of admission, when diagnostic status alters and within 30 days of discharge date. Complete any outstanding disease index coding

Discharge charts must include the following information prior to filing:

Final Diagnosis and/or Death Certificate

Completed Disease Index Coding

Obtain all outstanding documentation and required signatures to meet criteria mandated by facility policy.

Mail telephone order forms to physicians daily, assure prompt return and file in chart

Prepare Physician Orders, Medication/Treatment records, ADL records and Resident Care Plans for accurate input into computer and printing on scheduled basis

Perform computer operation functions including regular input of data and printing on a scheduled basis

Keep computer terminal(s), keyboard(s) and office clean and functional

Maintain appropriate medical record storage and destruction of medical records consistent with facility policy

Follow-up on reports and recommendations submitted by the Medical Records Consultants and Service Center Medical Records Analysts

Report to the Director of Nursing and Administrator significant documentation problems

Attend and participate in in-service education and staff meetings as required, including risk management and daily stand-up meetings. Maintain minutes of meetings/files as requested

Be courteous, considerate and cooperative when communication with all facility personnel, resident and public

React appropriately to emergencies and disaster situations

Job Functions:

Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions

Appreciates the importance of maintaining confidentiality of resident and facility information

Demonstrate honesty and integrity at all times in the care and use of resident and facility property

Must be able to key information into computer systems

Able to understand and to follow written and/or verbal directions. Able to express self adequately in oral and/or written communication. Able to communicate effectively with staff members, other professional staff, consultants and residents

Demonstrates ability to prioritize tasks/responsibilities and complete duties/projects within allotted time

Able to respond to change productively and to handle additional tasks/projects as assigned

Able to carryout the essential functions of this job (with or without reasonable accommodation) without posing specific, current risk of substantial harm to health and safety of self and others

Other duties as assigned by the Administrator

Qualifications/Requirements:

Education: High School graduate or equivalent

License: None Required

Work Experience: At least on year of clerical experience, including filing

Experience as a medical records practitioner in long term care facility preferred

Ability to type, calculate and perform data entry skills

Paid sick leave

PTO

Vision

401(k)

Life insurance

We provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, sex (including pregnancy, childbirth, or related condition), age, national origin or ancestry, citizenship, disability, marital status, sexual orientation, gender identity or expression (including transgender status), genetic predisposition or carrier status, military or veteran status, familial status, status as a victim of domestic violence, or any other status protected by law.