Job Title: Medical Records Director
Location: Oakwood Gardens Care Center - Fresno, CA
Employment Type: Full-Time
Starting Pay: $23.00 per hour
Job Summary

Oakwood Gardens Care Center, a skilled nursing facility in Fresno, CA, is seeking a detail-oriented and organized Medical Records Director to manage, organize, and maintain all aspects of health information management in accordance with federal, state, and facility guidelines. This vital role supports clinical operations, ensures regulatory compliance, and facilitates timely and accurate documentation that supports high-quality resident care.
Key Responsibilities

Department Oversight & Compliance

• Organize, plan, and direct the medical records department in accordance with facility policies and procedures
• Work closely with the Medical Records/Health Information Consultant
• Ensure proper filing, retrieval, and protection of all resident records, both electronic and physical
• Maintain documentation for incidents, accidents, admissions, discharges, and changes in resident status
• Assist MDS Coordinator in scheduling assessments in accordance with OBRA guidelines
• Maintain registries, such as admission and discharge logs
• Prepare and maintain records for audits and surveys

Documentation & Recordkeeping

• Collect, review, and file documentation including nurses' notes, assessments, lab reports, and physician correspondence
• Ensure records are complete, signed, coded, indexed, and filed accurately
• Track incomplete or missing records and ensure timely correction
• Maintain a log of all chart access and release of information per HIPAA regulations
• Retrieve and deliver records to authorized personnel upon request
• Maintain confidentiality and security of all protected health information (PHI)

Administrative & Secretarial Duties

• Maintain meeting minutes and assist with committee documentation and reports
• Respond to phone inquiries and correspondence related to medical records
• Prepare reports for insurance, Medicare, Medicaid, and other authorized agencies
• Index and batch resident information into EMR systems
• Assist physicians and clinical staff with transcription and medical documentation as needed

Supervisory & Staff Functions

• Supervise department staff and ensure task completion and policy adherence
• Provide training and take disciplinary action when necessary
• Ensure census information is current and report changes appropriately

Facility & Safety Support

• Maintain clean, organized workspaces and ensure supplies are stocked
• Report any unsafe conditions or equipment malfunctions to supervisors
• Assist in emergency situations, including evacuations if necessary

Qualifications

• High school diploma or GED required
• Knowledge of medical terminology, anatomy, and health information practices preferred
• Typing speed of 45 WPM and proficiency with computers and EMR systems
• Strong understanding of confidentiality and HIPAA regulations
• Ability to read, write, and communicate clearly in English
• On-the-job training provided

Skills & Abilities

• Excellent attention to detail and organizational skills
• Ability to make independent decisions and work with limited supervision
• Strong interpersonal skills and ability to work with diverse teams
• Flexibility to work beyond normal hours when needed

Physical Requirements

• Ability to lift/push/move up to 25 lbs.
• Must be able to sit, stand, walk, and move intermittently during the workday
• Capable of coping with emotional stress and interactions with upset residents or family members
• Ability to assist in emergencies or evacuations

Work Environment

• Office and facility-wide exposure
• Interacts with residents, families, facility staff, and external agencies
• Potential exposure to infectious materials and hazardous conditions

Join Oakwood Gardens Care Center and become part of a caring and professional team dedicated to improving the lives of our residents.
Apply today to take the next step in your healthcare career!