Medical Records Director - Skilled Nursing Leader

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

Benefits offered by this job

Competitive pay

Medical coverage

Dental coverage

Vision coverage

401(k)

Life insurance

Paid time off

Training & development

Collaborative team

Job summary

Oakwood Gardens Care Center seeks an experienced Full-Time Medical Records Director to oversee accuracy, security, and regulatory compliance of residents' medical records in a skilled-nursing setting.

The role requires knowledge of HIPAA, collaboration with nursing and medical staff, and leadership of the Medical Records Department to ensure complete, lawful, and timely documentation across admissions, transfers, and audits.

Qualifications

• High school diploma or GED required.
• Experience in skilled nursing or long-term care medical records preferred.
• Knowledge of HIPAA and health-information management.
• Familiarity with California requirements governing skilled nursing medical records.
• Experience with PointClickCare or another electronic health-record system preferred.
• Knowledge of ICD-10 coding and Medicare documentation helpful.
• RHIT, RHIA, or related health-information certification preferred but not required.
• Strong computer skills including Microsoft Office.
• Excellent organizational, analytical, and time-management abilities.
• Attention to detail and accuracy.

Responsibilities

• Organize, maintain, and oversee resident medical records per federal, state, and facility requirements.
• Ensure records are accurate, confidential, and available to authorized individuals.
• Establish and monitor medical-record policies, procedures, and filing systems.
• Review admission, readmission, transfer, and discharge records for accuracy.
• Audit resident charts to identify missing signatures and deficiencies.
• Maintain systems for tracking incomplete or delinquent documentation.
• Coordinate with physicians, nurses, therapy staff, and leaders to resolve deficiencies.
• Process physician orders, reports, and other documentation as required.
• Assist with ICD-10 coding and diagnostic information as permitted.
• Maintain census, admission, discharge, and transfer information.
• Prepare records for surveys, audits, legal requests, insurance reviews.
• Respond to requests for medical records and HIPAA compliance.

Skills

Organizational skills

Analytical thinking

Time management

Communication skills

Multitasking

Education

High school diploma

RHIT/RHIA

Tools

PointClickCare

Microsoft Office

Job description

Oakwood Gardens Care Center seeks an experienced Full-Time Medical Records Director to oversee accuracy, security, and regulatory compliance of residents' medical records in a skilled-nursing setting.

The role requires knowledge of HIPAA, collaboration with nursing and medical staff, and leadership of the Medical Records Department to ensure complete, lawful, and timely documentation across admissions, transfers, and audits.