Description

The Medical Records oversees the management, security, and accuracy of resident health records in compliance with federal, state, and facility regulations. This role ensures timely documentation, supports clinical and administrative staff, and maintains confidentiality and integrity of all medical information within the skilled nursing facility.

Essential Duties

• Manage the creation, maintenance, and storage of resident medical records in accordance with HIPAA and regulatory guidelines
• Ensure timely and accurate documentation of admissions, discharges, transfers, and clinical updates
• Monitor record completion and compliance with facility policies and state/federal requirements
• Coordinate with nursing, therapy, and administrative teams to support documentation needs
• Handle requests for medical records from residents, families, legal representatives, and outside providers
• Oversee electronic health record (EHR) systems and troubleshoot documentation issues
• Train and supervise medical records staff (if applicable)
• Prepare reports and audits for internal and external review
• Maintain confidentiality and safeguard sensitive health information
• Support survey readiness and respond to documentation-related inquiries from regulatory agencies

Qualification

Education and/or Experience

• Associate or bachelor's degree in Health Information Management preferred
• Certification as a Registered Health Information Technician (RHIT) or similar credential preferred
• Minimum 2 years of experience in medical records or health information management, preferably in long-term care
• Strong knowledge of HIPAA, Medicare/Medicaid documentation standards, and SNF regulations
• Proficiency in EHR systems and Microsoft Office
• Excellent organizational, communication, and problem-solving skills
• Ability to manage multiple priorities and meet deadlines

Physical Demands

• Frequent sitting, typing, and reviewing documents
• Occasional walking, standing, and lifting up to 25 lbs
• Ability to focus in a busy environment and handle confidential information with discretion

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually low to moderate.