Medical Records Director: HIPAA Compliance & Audits

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

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.