Medical Records Director Full-Time

Oakwood Gardens Care Center in; Fresno (CA); On-site; USD 28,000 - 34,000; Full time

Benefits offered by this job

Competitive pay

Full-time employment

Medical insurance

Dental insurance

Vision insurance

401(k) plan

Life insurance

Paid time off

Training and development

Collaborative team

Resident-centered care

Job summary

Oakwood Gardens Care Center in Fresno, CA is seeking a Medical Records Director to oversee the accuracy, security, and regulatory compliance of residents' medical records. This full-time role requires HIPAA knowledge, experience in skilled nursing, and proficiency with EHR systems like PointClickCare.

You will collaborate with nursing, therapy, physicians, and administration to ensure timely, complete documentation.

Qualifications

• High school diploma or GED required.
• Experience in a skilled nursing or long-term care setting preferred.
• Knowledge of HIPAA and resident confidentiality.
• Familiarity with California state requirements for medical records.
• Experience with EHR systems, preferably PointClickCare.
• RHIT/RHIA certification preferred but not required.
• Strong computer skills with Microsoft Office.

Responsibilities

• Organize, maintain, and oversee resident medical records in accordance with federal, state, and facility requirements.
• Ensure medical records are accurate, complete, confidential, and readily available to authorized individuals.
• Audit resident charts for missing signatures, incomplete documentation, outdated orders, and other deficiencies.
• Maintain systems for tracking incomplete documentation.
• Coordinate with physicians, nurses, therapy staff, and department leaders to resolve documentation deficiencies promptly.
• Process physician orders, reports, diagnostic results, consultations, and other documentation according to established procedures.
• Assist with ICD-10 coding and diagnostic information as permitted by facility policy and individual qualifications.
• Maintain accurate resident census, admission, discharge, and transfer information.
• Prepare records for facility surveys, audits, legal requests, insurance reviews, and other authorized purposes.
• Respond to requests for medical records and PHI in accordance with HIPAA and facility policies.
• Obtain proper authorization before releasing resident information.
• Maintain logs for record requests, disclosures, chart locations, and other required tracking.
• Safeguard electronic and paper medical records from unauthorized access, loss, alteration, or destruction.

Skills

HIPAA knowledge

Organizational skills

Attention to detail

Strong communication

Proficiency with Microsoft Office

EHR familiarity

Education

High School Diploma or GED

RHIT/RHIA certification preferred

Tools

PointClickCare

Job description

Medical Records Director – Full-Time Oakwood Gardens Care Center Pay Range: $20.00–$25.00 per hour, based on experience

Join Our Skilled Nursing Leadership Team Oakwood Gardens Care Center is seeking an experienced, organized, and highly detail-oriented Full-Time Medical Records Director to oversee the accuracy, security, and regulatory compliance of our residents’ medical records. The ideal candidate will have experience in skilled nursing or long-term care medical records, strong knowledge of HIPAA requirements, and the ability to collaborate effectively with nursing, therapy, physicians, administration, and other departments.

Essential Duties and Responsibilities

• Organize, maintain, and oversee resident medical records in accordance with federal, state, and facility requirements.
• Ensure medical records are accurate, complete, confidential, and readily available to authorized individuals.
• Establish, maintain, and monitor medical-record policies, procedures, and filing systems.
• Review admission, readmission, transfer, and discharge records for accuracy and completeness.
• Audit resident charts regularly to identify missing signatures, incomplete documentation, outdated orders, and other deficiencies.
• Maintain systems for tracking and obtaining incomplete or delinquent documentation.
• Coordinate with physicians, licensed nurses, therapy staff, and department leaders to resolve documentation deficiencies promptly.
• Process physician orders, reports, diagnostic results, consultations, and other documentation according to established procedures.
• Assist with ICD-10 coding and diagnostic information as permitted by facility policy and individual qualifications.
• Maintain accurate resident census, admission, discharge, and transfer information.
• Prepare records for facility surveys, audits, legal requests, insurance reviews, and other authorized purposes.
• Respond to requests for medical records and protected health information in accordance with HIPAA and facility policies.
• Obtain proper authorization before releasing resident information.
• Maintain logs for record requests, disclosures, chart locations, and other required tracking.
• Safeguard electronic and paper medical records from unauthorized access, loss, alteration, or destruction.
• Follow established record-retention, storage, archiving, and destruction requirements.
• Support quality-assurance and performance-improvement activities related to documentation and medical records.
• Participate in facility meetings, audits, surveys, and regulatory inspections as requested.
• Assist department leaders with documentation education and compliance.
• Maintain resident privacy and immediately report suspected or known confidentiality violations.
• Communicate professionally with residents, families, physicians, staff, government representatives, and outside organisations.
• Perform additional duties as assigned by the Administrator or facility leadership.

Qualifications

• High school diploma or GED required.
• Previous medical-records experience in a skilled nursing or long-term care facility strongly preferred.
• Knowledge of HIPAA, resident confidentiality, medical terminology, and health-information management practices.
• Familiarity with federal and California requirements governing skilled nursing medical records preferred.
• Experience with PointClickCare or another electronic health-record system preferred.
• Knowledge of ICD-10 coding and Medicare documentation requirements is helpful.
• RHIT, RHIA, or related health-information certification is preferred but not required.
• Strong computer skills, including proficiency with Microsoft Office.
• Excellent organisational, analytical, and time-management abilities.
• Exceptional attention to detail and commitment to accuracy.
• Ability to prioritise multiple responsibilities and meet established deadlines.
• Strong written and verbal communication skills.
• Ability to maintain professionalism and confidentiality at all times.

Supervisory Responsibilities

The Medical Records Director oversees the daily operation of the Medical Records Department and may provide direction or training to assigned staff. Supervisory responsibilities will depend on the facility’s organisational structure.

Physical Requirements

This position requires regular sitting, standing, walking, speaking, hearing, reading, and prolonged computer use. Frequent use of telephones, scanners, copiers, and other office equipment is required. The employee may occasionally lift or move files, storage boxes, or supplies weighing up to 25 pounds. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position.

Why Join Oakwood Gardens Care Center?

• Competitive pay of $20.00–$25.00 per hour, based on experience
• Full-time employment
• Medical, dental, and vision insurance
• 401(k) retirement plan
• Life insurance
• Paid time off
• Training and professional-development opportunities
• Supportive leadership and a collaborative interdisciplinary team
• Rewarding work in a resident-centered skilled nursing environment

Benefits are subject to eligibility requirements and facility policy.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.

Employment decisions are based on qualifications, merit, and business needs.