Senior Medical Records Director - Skilled Nursing Leader

PACS; Fresno (CA); Sur place; USD 28 000 - 34 000; Plein temps

Avantages offerts par ce poste

Medical insurance

Dental insurance

Vision insurance

401(k) retirement plan

Life insurance

Paid time off

Training and professional development

Collaborative interdisciplinary team

Résumé du poste

Oakwood Gardens Care Center in Fresno, CA is seeking a Full-Time Medical Records Director to oversee the accuracy, security, and regulatory compliance of residents’ medical records.

The ideal candidate will have experience in skilled nursing or long‑term care, strong HIPAA knowledge, and the ability to collaborate with nursing, therapy, physicians, and administration to maintain compliant records. This role also supports compliance initiatives and ensures timely documentation.

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 organizational, analytical, and time-management abilities.
• Exceptional attention to detail and commitment to accuracy.
• Ability to prioritize multiple responsibilities and meet established deadlines.
• Strong written and verbal communication skills.
• Ability to maintain professionalism and confidentiality at all times.

Responsabilités

• 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• Audit resident charts regularly to identify missing signatures, incomplete documentation, outdated orders, and other deficiencies.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 organizations.
• Perform additional duties as assigned by the Administrator or facility leadership.

Connaissances

HIPAA knowledge

Organization

Communication

Time management

Multitasking

Formation

High school diploma or GED

RHIT/RHIA certification preferred

Outils

PointClickCare

Microsoft Office

Description du poste

Oakwood Gardens Care Center in Fresno, CA is seeking a Full-Time Medical Records Director to oversee the accuracy, security, and regulatory compliance of residents’ medical records.

The ideal candidate will have experience in skilled nursing or long‑term care, strong HIPAA knowledge, and the ability to collaborate with nursing, therapy, physicians, and administration to maintain compliant records. This role also supports compliance initiatives and ensures timely documentation.