Medical Records Director

Kalesta Healthcare Group; Pullman (WA); On-site; USD 37,000 - 47,000; Full time

Benefits offered by this job

Competitive pay

Medical, dental, vision insurance

401(k)

Paid time off

Ongoing training

Job summary

Three Creeks Post Acute in Pullman, WA seeks a detail-driven Medical Records Director to own clinical documentation from admission to discharge. You will ensure chart accuracy, audit readiness, and HIPAA compliance while collaborating with the Administrator and nursing leadership.

The role involves leading records operations, EMR data entry, and periodic audits; you will issue deficiency reports and manage discharge documentation to keep the facility survey-ready.

Qualifications

• High school diploma or equivalent.
• At least 1 year of clerical or records experience.
• Long-term care or skilled nursing medical records experience preferred.
• Proficiency with EMR systems and data entry.
• Solid knowledge of HIPAA and confidentiality standards.
• Strong organizational and prioritization skills with ability to meet deadlines.
• Clear, professional communication with staff, physicians, residents, families, and outside agencies.
• Ability to sit for extended periods and lift up to 25 lbs.
• Annual TB screening and physical exam required.

Responsibilities

• Lead all medical records operations: assembling, organizing, filing, purging, storing, and destroying records per policy and regulations.
• Manage EMR data entry and maintain accurate, accessible resident records.
• Run audits on a rotation: admission, 7/14/21‑day reviews, MDS, care plans, physician visits, orders, and incident reports.
• Issue deficiency reports and ensure corrections within 3 days.
• Complete disease index coding at admission and within 30 days of discharge.
• Close discharge charts with final diagnoses, signatures, and documentation.
• Process records requests from authorized individuals and outside institutions.
• Prepare physician orders, MAR/TAR, ADL records, and care plans for printing.
• Track and return physician telephone orders promptly.
• Compile statistical data and reports as directed by the Administrator.
• Follow up on consultants' recommendations and report issues to DON/Administrator.
• Participate in daily stand-ups, risk management, and staff meetings; keep minutes.

Skills

Attention to detail

HIPAA compliance

EMR data entry

Documentation standards

Communication skills

Education

High school diploma or equivalent

Tools

EMR systems

Job description

Medical Records Director | $27–$34/hr | Three Creeks Post Acute - Pullman, WA

Bring order, accuracy, and accountability to a skilled nursing team that depends on you.

Three Creeks Post Acute in Pullman, WA is looking for a detail-driven Medical Records Director to own clinical documentation from admission to discharge. You'll be the go-to person for chart accuracy, audit readiness, and HIPAA compliance, reporting directly to the Administrator and working closely with nursing leadership. If you like building systems, catching what others miss, and keeping a facility survey-ready, this role was built for you.

What You'll Do

• Lead all medical records operations: assembling, organizing, filing, purging, storing, and destroying records in line with facility policy and state/federal regulations

• Manage EMR data entry and maintain accurate, accessible, well-organized resident records

• Run concurrent and discharge audits on a scheduled rotation, including admission audits (24/48 hr), 7/14/21-day reviews, MDS, care plans, physician visits, telephone orders, psychotropics, weights, skin/wound documentation, labs, therapy, and incident reports

• Issue deficiency reports to responsible staff and follow up to make sure corrections are completed within 3 days

• Complete disease index coding at admission, with changes in diagnostic status, and within 30 days of discharge

• Close out discharge charts with final diagnoses, required signatures, and all outstanding documentation

• Process records requests from authorized individuals and outside institutions; request records from transferring facilities

• Prepare physician orders, MAR/TAR, ADL records, and care plans for scheduled printing

• Track and return physician telephone orders promptly

• Compile statistical data and reports at the direction of the Administrator

• Follow up on recommendations from medical records consultants and report significant documentation issues to the DON and Administrator

• Take part in daily stand-up, risk management, and staff meetings, and keep meeting minutes as needed

Why Work at Three Creeks Post Acute

• Leadership role with direct access to the Administrator and a real voice in compliance

• Stable, full-time position with a predictable, primarily office-based schedule

• Meaningful work: accurate records directly protect resident care in the Pullman community

• A supportive team that values accuracy, integrity, and follow-through

Benefits

• Competitive pay: $27–$34/hr, based on experience

• Medical, dental, and vision insurance

• 401(k)

• Paid time off and holidays

• Ongoing training and in-service education

What You'll Need

• High school diploma or equivalent

• At least 1 year of clerical or records experience, including filing

• Long-term care or skilled nursing medical records experience strongly preferred

• Comfort with EMR systems and strong typing and data entry skills

• Solid working knowledge of HIPAA and confidentiality standards

• Strong organizational and prioritization skills, with the ability to meet deadlines

• Clear, professional communication with staff, physicians, residents, families, and outside agencies

• Ability to sit for extended periods and lift up to 25 lbs

• Annual TB screening and physical exam required

Three Creeks Post Acute is 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, veteran status, or any other protected characteristic under applicable law.