Medical Records Director Skilled Nursing Facility

Highland Park Rehabilitation & Care; Aurora (CO); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Competitive benefits

Professional growth

Supportive team environment

Job summary

Highland Park Rehabilitation & Care is seeking a Medical Records Director (HIM) to oversee accurate, timely, and confidential maintenance of resident health records in compliance with Colorado state regulations, federal requirements, and facility policies. The role supports clinical operations, survey readiness, and the integrity of health information within our skilled nursing setting.

The candidate will manage active/inactive records, ensure documentation meets regulatory deadlines, and

Qualifications

• Maintain, organize, and secure medical records in compliance with CDPH, CMS regulations, and facility policies.
• Review medical charts for accuracy; follow up with nursing and staff to resolve deficiencies within required timeframes.
• Ensure documentation meets Colorado survey readiness standards at all times.
• Coordinate the release of health information in accordance with HIPAA, Colorado privacy laws, and facility authorization procedures.
• Prepare and maintain reports, logs, and other required documentation for State inspections, state and federal surveys, and internal audits.

Responsibilities

• Maintain active and inactive medical records in compliance with regulatory requirements.
• Review charts for accuracy and resolve deficiencies with nursing and staff.
• Support survey readiness and regulatory compliance across the facility.
• Coordinate health information releases while adhering to HIPAA and privacy laws.
• Prepare reports and logs for inspections, surveys, and audits.
• Maintain strict confidentiality and protect resident information.

Skills

Verbal and written communication

Organization & detail orientation

Regulatory awareness

Education

High school diploma or equivalent

HIM coursework preferred

Tools

EHR systems

Microsoft Office

Job description

At Sweetwater Care, we believe in creating a supportive, compassionate, and collaborative environment where both our residents and team members can thrive. Our Highland Park Rehab and Care community is proud to have a dedicated team with many long-tenured staff members who b ring exceptional experience and heart to the work we do each day.

Rooted in integrity, respect, teamwork, and a commitment to excellence, we take pride in providing high-quality care while fostering a workplace where employees feel valued and supported.

If you're looking to build a meaningful career in a stable and mission-driven organization, we invite you to join our team!

The Medical Records Director (HIM) position is a new addition to the team and is responsible for the accurate, timely, and confidential maintenance of resident health information and medical records in accordance with Colorado state regulations, federal requirements, and facility policies.

This position plays a vital role in supporting clinical operations, survey readiness, and ensuring the integrity of resident health information within our skilled nursing facility.

Essential Duties and Responsibilities:

• Maintain, organize, and secure active and inactive medical records in compliance with CDPH, CMS regulations, and facility policies.
• Review medical charts for accuracy and completeness; follow up with nursing and ancillary staff to resolve deficiencies within required timeframes
• Ensure documentation meets Colorado survey readiness standards at all times
• Coordinate the release of health information in accordance with HIPAA, Colorado privacy laws, and facility authorization procedures.
• Prepare and maintain reports, logs, and other required documentation for State inspections, state and federal surveys, and internal audits.
• Manage record retention and destruction according to Colorado state retention schedules and facility procedures.
• Provide timely and accurate health information to interdisciplinary team members to support resident care and clinical decision-making.
• Participate in Quality Assurance and performance Improvement (QAPI) initiatives related to documentation and record accuracy.
• Maintain strict confidentiality and comply with all privacy and security regulations.

Qualifications:

• High school diploma or equivalent required; post-secondary education or HIM coursework preferred.
• Minimum of 1 year of experience in a skilled nursing or long-term care setting preferred
• Proficiency in electronic health record (EHR) systems and Microsoft Office applications
• Strong organizational skills, attention to detail, and ability to meet regulatory deadlines.
• Excellent verbal and written communication skills
• Ability to work independently and as part of a multidisciplinary team.

Benefits:

• Competitive compensation and comprehensive benefits package
• Opportunities for professional growth and advancement
• Supportive team environment with a focus on regulatory excellence and resident care.