Medical Records Director

Job Description

Job Description

Medical Records DirectorPosition Summary

The Medical Records Director is responsible for maintaining resident medical records in compliance with federal, state, and facility requirements. This position oversees medical record accuracy, confidentiality, audits, record retention, and documentation compliance while supporting resident care operations and regulatory standards.

Key Responsibilities

• Maintain and organize resident medical records, both electronic and hard copy.

• Ensure medical record compliance with federal, state, and facility regulations.

• Monitor documentation accuracy and conduct routine chart audits.

• Manage admissions, discharges, record retention, and record destruction processes.

• Process medical record requests in accordance with facility policies and privacy regulations.

• Maintain confidentiality and ensure compliance with HIPAA and resident privacy standards.

• Assist with Quality Improvement activities related to medical records and documentation.

• Report documentation deficiencies and compliance concerns to facility leadership.

• Coordinate resident appointments and transportation as needed.

• Maintain accurate filing systems and ensure records are complete and readily accessible.

• Support department operations and perform other duties as assigned.

Qualifications

• Must be at least 21 years of age.

• Previous medical records experience in a healthcare setting preferred.

• Knowledge of medical terminology, documentation standards, and HIPAA requirements.

• Strong organizational, communication, and time management skills.

• Ability to maintain confidentiality and handle sensitive information.

• Ability to work independently and collaboratively with residents, families, staff, and healthcare professionals.

• Proficient in electronic medical record systems and basic computer applications.

Physical Requirements

• Ability to sit, stand, walk, bend, and lift as required throughout the workday.

• Ability to respond appropriately during emergency situations.

• Ability to effectively communicate and interact with residents, families, staff, and visitors.