The posting
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.
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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 Accredited Records Technician (ART) or equivalent.
- 1+ year of medical records experience in long-term care.
Preferred:
- Certification as Registered Records Administrator (RRA).
- Supervisory experience in SNF HIM department.
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