Medical Records Director - Full-Time Canyon Springs Post Acute | San Jose, CA Salary: $70,000-$80,000 annually, depending on experience Schedule: Full-Time Benefits: Competitive benefits package
Key Responsibilities
- Oversee the creation, organization, maintenance, storage, and retrieval of resident medical records in compliance with HIPAA and applicable state and federal regulations.
- Ensure timely and accurate documentation of resident admissions, discharges, transfers, and clinical updates.
- Monitor medical records for completeness, accuracy, and compliance with facility policies and regulatory requirements.
- Coordinate with nursing, rehabilitation, and administrative departments to ensure documentation is completed accurately and on time.
- Manage requests for medical records from residents, families, legal representatives, healthcare providers, and authorized agencies.
- Oversee electronic health record (EHR) systems and resolve documentation issues as needed.
- Conduct routine medical records audits and prepare reports for internal reviews, external audits, and regulatory inspections.
- Maintain strict confidentiality and safeguard protected health information.
- Support facility survey readiness and respond to documentation-related inquiries from regulatory agencies.
- Develop, implement, and maintain medical records policies and procedures.
- Identify opportunities to improve documentation accuracy, workflow efficiency, and regulatory compliance.
- Ensure records are properly indexed, filed, retained, and released in accordance with established policies.
Leadership and Supervisory Responsibilities
- Supervise and support medical records staff, as applicable.
- Provide training and guidance on documentation standards, confidentiality, and regulatory compliance.
- Coordinate staffing schedules and monitor departmental performance.
- Establish expectations for accuracy, timeliness, and adherence to facility policies.
- Collaborate with facility leadership to address documentation concerns and improve departmental operations.
Qualifications
- Previous medical records experience required.
- Minimum of 2 years of experience in medical records or health information management; skilled nursing or long-term care experience strongly preferred.
- Associate or bachelor's degree in Health Information Management preferred.
- RHIT certification or a similar health information management credential preferred.
- Strong knowledge of HIPAA, Medicare/Medicaid documentation standards, and skilled nursing facility regulations.
- Experience working with electronic health record systems and Microsoft Office.
- Excellent organizational, communication, leadership, and problem-solving skills.
- Ability to manage multiple priorities, meet deadlines, and maintain accuracy in a fast-paced healthcare environment.
- Demonstrated commitment to confidentiality, regulatory compliance, and quality documentation.
Compensation and Benefits
- Annual salary: $70,000-$80,000, depending on experience
- Full-time position
- Competitive benefits package
- Opportunity to contribute to quality resident care and regulatory compliance
- Collaborative healthcare team environment
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.
We celebrate diversity and are committed to creating an inclusive environment for all employees. We welcome applicants of every race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, and any other protected characteristic.
PACS is revolutionizing the delivery and leadership of post-acute healthcare and support services across the country. Originally founded in 2013, the organization now consists of hundreds of independent operating subsidiaries, as well as ancillary and support services. We bring a proven model of mission-driven care that balances access to a national network of support and resources with local decision making. In addition, PACS helps connect exceptional people with premier healthcare careers across the country. We focus on finding innovative and effective team members based on their qualifications, experience, geographic preferences, and personality fit with the existing facility staff and culture.
Employment decisions are based on qualifications, merit, and business needs.