Medical Records Director

The Win Post-Acute; Santa Clara (CA); On-site; USD 95,000 - 130,000; Full time

Benefits offered by this job

Competitive pay

Health Benefits – Medical, dental, and

Vision coverages with company paying a

401(k) with discretionary company

Life and disability insurance

Paid Time Off

Employee Assistance program

Tuition Assistance and Profession Enh

Bene-Hub discounts

Job summary

The Win is seeking a Medical Records Director to maintain resident medical records and health information systems at its Santa Clara facility. You will oversee chart review, filing, HIPAA compliance, and staff supervision to ensure accurate documentation and regulatory adherence.

The role requires a minimum of three years in medical records, a bachelor’s degree or equivalent, and Point Click Care experience is preferred.

Qualifications

• Minimum three years in medical records at a health care facility.
• Bachelor’s degree or equivalent education/experience.
• Point Click Care experience preferred.

Responsibilities

• Review admission and discharge records and nursing unit records.
• Collect, assemble, check, and file resident charts and personnel records.
• Ensure incomplete records are returned to the appropriate department.
• Ensure established policies and procedures governing medical records and HIPAA are followed.
• Audit and complete ongoing review of all patients’ clinical records for documentation and compliance.
• Maintain current, overflow, and discharged record filing systems.
• Serve as the facility’s Privacy Officer for HIPAA compliance.
• Effectively communicate with physicians, nursing staff, and allied health personnel.
• Interview, hire, train, evaluate, counsel, and supervise medical records staff.
• Prepare closed charts.
• Assume responsibility for diagnostic admission and discharge coding index.
• Ensure all Physician Orders are signed timely.
• Ensure Medicare Certifications and Re-certifications are signed timely.
• Notify MDs regarding compliance of customer visits and progress notes.
• Coordinate with Pharmacy on MAR additions/deletions.
• Obtain signatures on discharge charts within 30 days of discharge.
• Attend QAPI, triple check and Medicare meetings.

Skills

Medical Records Experience

Education

Bachelor’s degree or equivalent

Tools

Point Click Care

Job description

Medical Records Director

Position Summary:

Maintain resident medical records and health information systems

Qualifications:

• Minimum, three (3) years’ experience in medical records of a health care facility
• Bachelor’s degree OR an equivalent combination of education and experience
• Point Click Care Experience preferred

Responsibilities:

• Review of admission and discharge records, as well as records on the nursing units
• Collect, assemble, check, and file resident charts and personnel records
• Ensure that incomplete records/charts are returned to the appropriate department
• Ensure established policies and procedures governing medical records and health information is followed by all personnel
• Audit and complete ongoing review of all patients’ clinical records to ensure documentation and performance compliance
• Maintain curent, overflow, and discharged record filing systems
• Serve as the facility’s Privacy Officer for HIPAA compliance
• Effectively communicate with physicians, nursing staff, and allied health personnel
• Interview, hire, train, evaluate, counsel, and supervise medical records staff
• Prepares closed charts
• Assume responsibility for diagnostic admission and discharge coding index
• Ensure that all Physician Orders are signed in a timely manner
• Ensure all Medicare Certifications and Re-certifications are signed in a timely manner
• Notify MDs in reference to compliance of customer visits and progress notes
• Communicate with Pharmacy in reference to additions/deletions of customer MARs.
• Obtain all appropriate departmental and physicians' signatures on discharge charts within 30 days of discharge
• Attend QAPI, triple check and medicare meetings

Benefits:

• Competitive pay
• Health Benefits – Medical, dental, and vision coverages with company paying a substantial portion of costs (voluntary supplemental plan options available)
• 401(k) with discretionary company match annually
• Company paid Basic Life and disability insurance (Buy up options available)
• Paid Time Off (Vacation, Sick, Holiday)
• Employee Assistance program
• Tuition Assistance and Profession Enhancement Funds
• Bene-Hub employee sponsored discount programs and more….

We are proud to be an equal opportunity employer.

*Benefits available to full-time employees.

The Win is a 24-hour skilled nursing facility located in Santa Clara. Our team of dedicated healthcare professionals works to help patients recover from surgery, injury or serious illness.
As a team, we strive to exceed the expectations of those we serve and our purpose is to provide our patients with positive rehabilitative therapy and exceptional nursing care. We want to help patients achieve their highest possible functioning level and to assist them in returning to the lowest level of care practical.