Medical Records Director

Director of Medical Records

Department: Medical Records / Health Information Management

Location: Facility Level – Optalis Health & Rehabilitation

Reports To: Administrator

FLSA Status: Salary Exempt

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Position Summary:

The Director of Medical Records oversees recordkeeping, storage, and management of all clinical records. This role ensures compliance with CMS, HIPAA, and state/federal regulations while supervising HIM staff and maintaining accurate, accessible, and confidential records to support resident care and survey readiness.

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Key Responsibilities:

• Develop and maintain policies to ensure medical records are accurate, complete, and accessible.
• Oversee record storage, retrieval, and retention systems in compliance with regulations.
• Ensure confidentiality of resident information and compliance with HIPAA.
• Support interdisciplinary care planning by providing timely access to resident records.
• Train and supervise HIM/medical records staff.
• Prepare for surveys and audits, responding to regulatory requests for records.
• Collaborate with administrators, physicians, and nursing staff on documentation practices.
• Oversee all Medical Coding.

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Skills & Competencies

• Knowledge of HIM practices and SNF medical record requirements.
• Strong supervisory and organizational skills.
• Proficiency with EHR systems and Microsoft Office Suite.
• Ability to interpret and apply healthcare regulations.

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Required:

• High school diploma or equivalent.
• Certification as RHIT, RHIA, CCA, CCS, or CPC
• 1+ year of medical records experience in long-term care.

Preferred:

• Supervisory experience in SNF HIM department.