Medical Records Director Full-Time

Medical Records Director - Full-Time

Oakwood Gardens Care Center
Pay Range: $20.00-$25.00 per hour, based on experience
Join Our Skilled Nursing Leadership Team

Oakwood Gardens Care Center is seeking an experienced, organized, and highly detail-oriented Full-Time Medical Records Director to oversee the accuracy, security, and regulatory compliance of our residents' medical records.

The ideal candidate will have experience in skilled nursing or long-term care medical records, strong knowledge of HIPAA requirements, and the ability to collaborate effectively with nursing, therapy, physicians, administration, and other departments.
Essential Duties and 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.


* 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* Audit resident charts regularly to identify missing signatures, incomplete documentation, outdated orders, and other deficiencies.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...