Medical Records Director — Skilled Nursing Leader

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• Audit resident charts for missing signatures, incomplete documentation, outdated orders, and other deficiencies.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

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.