Medical Records Director

Sequoia Transitional Care is seeking an organized, knowledgeable, and detail-oriented Medical Records Director to oversee the accuracy, security, and regulatory compliance of resident health records. This position works closely with clinical and administrative teams to ensure documentation is complete, timely, confidential, and survey-ready.

Compensation

Pay Range: $20.00–$25.00 per hour, based on experience

General Purpose

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

Essential Duties and Responsibilities

• Manage the creation, maintenance, organization, retention, and storage of resident medical records.
• Ensure records comply with HIPAA, federal and state regulations, and facility policies.
• Maintain accurate documentation for resident admissions, discharges, transfers, and clinical updates.
• Monitor medical records for completeness, accuracy, proper signatures, and timely completion.
• Conduct routine audits and follow up with appropriate departments regarding missing or incomplete documentation.
• Coordinate with nursing, therapy, social services, business office, and administrative teams to support documentation needs.
• Process medical record requests from residents, authorized family members, legal representatives, outside providers, and government agencies.
• Verify that proper authorizations are obtained before releasing protected health information.
• Oversee electronic health record systems and assist staff with documentation or access issues.
• Prepare reports, audits, and documentation for internal reviews, surveys, and regulatory inspections.
• Maintain confidentiality and safeguard sensitive resident and facility information.
• Support survey readiness and respond to documentation-related inquiries from regulatory agencies.
• Organize archived records according to retention requirements.
• Perform additional duties as assigned by the Administrator.

Supervisory Responsibilities

The Medical Records Director may supervise medical records staff and provide training, scheduling, guidance, and performance oversight. This position ensures assigned staff comply with HIPAA requirements, documentation standards, and facility policies.

Qualifications

Education and Experience

• Associate or bachelor’s degree in Health Information Management or a related field preferred.
• Registered Health Information Technician certification or a similar credential preferred.
• Minimum of two years of experience in medical records or health information management preferred.
• Previous experience in a skilled nursing, post-acute, or long-term care setting strongly preferred.
• Strong knowledge of HIPAA requirements, Medicare and Medicaid documentation standards, and skilled nursing regulations.
• Proficiency with electronic health record systems and Microsoft Office.
• Excellent organizational, communication, and problem-solving skills.
• Strong attention to detail and the ability to maintain accurate records.
• Ability to manage multiple priorities and meet required deadlines.
• Ability to handle confidential information with professionalism and discretion.

Physical Demands

• Frequent sitting, typing, filing, and reviewing electronic and paper documents.
• Occasional walking, standing, bending, reaching, and lifting up to 25 pounds.
• Ability to work efficiently and maintain focus in a busy healthcare environment.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

Work Environment

The work environment is generally professional, with a low to moderate noise level. The Medical Records Director regularly interacts with residents, families, employees, healthcare providers, and regulatory representati