Medical Records Director

Canyon Springs Post Acute; San Jose (CA); On-site; USD 70,000 - 80,000; Full time

Benefits offered by this job

Competitive benefits package

Collaborative healthcare team

Job summary

Canyon Springs Post Acute in San Jose, CA is seeking an experienced Medical Records Director to oversee our medical records department, ensuring accuracy, security, and regulatory compliance of resident health information.

The ideal candidate will have 2+ years in medical records or health information management, experience with EHR systems, HIPAA knowledge, and strong leadership to coordinate documentation across nursing and administrative teams.

Qualifications

• Minimum 2 years 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.

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.

Skills

Medical records management

HIPAA compliance

Regulatory documentation

Leadership

Communication

Education

Associate degree in Health Information Management

Bachelor’s degree in Health Information Management

Tools

EHR systems

Microsoft Office

Job description

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

Join Our Team at Canyon Springs Post Acute!

Canyon Springs Post Acute is seeking an experienced and detail-oriented Medical Records Director to oversee our medical records department and ensure the accuracy, security, and compliance of resident health information.

This is an excellent opportunity for a healthcare professional with skilled nursing or long-term care experience who understands medical records management, regulatory compliance, and the importance of maintaining complete and confidential resident documentation.

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.