Medical Records Director

Medical Records Director Confidential Encinitas, CA Job Details Full-time $69,000 - $79,000 a year 1 hour ago Benefits Health insurance Dental insurance 401(k) Paid time off Vision insurance Life insurance Qualifications Long-term care regulations Healthcare staff management Electronic health records (EHR) management Team leadership

CMS HIPAA

Healthcare documentation compliance audits Long-term care facility experience High school diploma or GED CMS regulatory compliance Supervising experience Medical records Health information regulatory compliance Regulatory readiness in healthcare Typing Health information management Quality audits Clinical confidentiality policies Clinical documentation standards Managing patient records Medical terminology

Full Job Description Job Title:

Medical Records Director Aviara Healthcare Center is seeking an experienced and organized Medical Records Director to join our team. The Medical Records Director is responsible for overseeing the maintenance, security, accuracy, and completeness of resident medical records while ensuring compliance with all federal, state, and facility regulations. Position Summary The Medical Records Director manages the Medical Records Department and ensures that resident health information is maintained accurately, confidentially, and in accordance with HIPAA, CMS, and California Department of Public Health regulations. This position works closely with nursing, therapy, social services, physicians, and administration to support quality resident care and regulatory compliance. Essential Duties and ResponsibilitiesMedical Records Management Maintain resident medical records in an organized, accurate, and timely manner. Ensure all medical records are complete, signed, dated, and properly filed. Monitor physician orders, assessments, care plans, and clinical documentation for completeness. Assemble, analyze, maintain, and archive active and discharged resident records. Manage electronic health records (EHR) and paper records as applicable. Process admissions, transfers, and discharges related to medical record documentation. Compliance and Confidentiality Ensure compliance with HIPAA, CMS, state, and facility regulations. Maintain the confidentiality and security of all resident health information. Prepare records for state surveys, audits, legal requests, and regulatory reviews. Monitor documentation compliance and communicate deficiencies to appropriate departments. Release of Information Process requests for medical records from residents, families, physicians, hospitals, attorneys, and regulatory agencies. Verify proper authorization before releasing protected health information. Maintain accurate logs of record requests and disclosures. Quality Assurance Conduct routine chart audits and identify incomplete or delinquent documentation. Follow up with physicians and interdisciplinary team members regarding record deficiencies. Participate in Quality Assurance and Performance Improvement (QAPI) activities. Assist departments in maintaining compliance with documentation standards. Department Coordination Collaborate with nursing, rehabilitation, social services, MDS, and administration teams. Provide guidance and education regarding documentation and medical record requirements. Assist with census reporting, record retention, and departmental processes. Maintain organized filing systems and ensure records are readily available when needed. QualificationsRequired High school diploma or equivalent. Minimum of 3 years of Medical Records experience in a Skilled Nursing Facility (SNF), including at least 1 year in a supervisory or leadership role. Experience managing electronic health record (EHR) systems. Strong knowledge of

HIPAA, CMS

regulations, medical record standards, and California Department of Public Health requirements. Experience preparing for and supporting state surveys and regulatory audits. Strong organizational, communication, and time management skills. Ability to maintain strict confidentiality and handle sensitive information professionally. Preferred Associate degree in Health Information Management or a related field. Experience in long-term care, rehabilitation, or post-acute care settings. Previous experience supervising staff and managing department operations. Benefits Competitive pay Health, dental, and vision insurance Paid time off 401(k) Opportunities for professional growth and development Schedule Full-Time Monday through Friday Occasional flexibility may be required during surveys, audits, or special projects Work Location In-person Aviara Healthcare Center is an Equal Opportunity Employer and is committed to providing quality care through teamwork, professionalism, and excellence in service.

Job Type:

Full-time Pay:

$69,000.00 - $79,000.00 per year

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance Ability to

Commute:

Encinitas, CA 92024 (Required) Ability to

Relocate:

Encinitas, CA 92024: Relocate before starting work (Required)

Work Location:

In person