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Director Medical Record Jobs in Indiana (NOW HIRING)

PACS Inc

Medical Records Assistant

Evansville, IN · On-site

... directing the medical records department in accordance with established policies and procedures ... • Assist the Medical Records/Health Information Consultant as required. • Maintain minutes of ...

Pacs

Medical Records Assistant

Reo, IN · On-site

Index medical records as directed by the medical records/health information consultant. Maintain ... various registries as directed including register for admission and discharge of residents.

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Director Medical Record information

What are some typical challenges faced by a director medical record, and how can they be addressed?

Directors of Medical Records often encounter challenges such as ensuring compliance with ever-changing healthcare regulations, managing large volumes of confidential data, and leading a diverse team. Staying current with HIPAA and other regulatory requirements is essential, as is implementing robust electronic health record (EHR) systems to safeguard patient privacy. Effective communication and ongoing staff training help maintain high standards, while fostering collaboration with clinical and administrative teams can streamline processes and improve record accuracy.

What is a director medical record?

A Director of Medical Records is a healthcare professional responsible for overseeing the management, security, and accuracy of patient health records within a medical facility. They ensure compliance with healthcare regulations, supervise medical records staff, and implement policies for proper documentation and record-keeping. Their role is vital for maintaining patient confidentiality and supporting quality patient care through efficient information management.

What is the difference between Director Medical Record vs Medical Records Coordinator?

AspectDirector Medical RecordMedical Records Coordinator
CredentialsTypically requires a healthcare management or health information management degree, with certifications like RHIA or RHITUsually requires a high school diploma or associate degree, with certifications like Certified Medical Administrative Assistant (CMAA)
Work EnvironmentOversees medical record departments in hospitals, clinics, or healthcare systemsWorks within healthcare facilities managing patient records and data entry
ResponsibilitiesStrategic management, policy development, compliance oversightData entry, record organization, patient information updates

The Director Medical Record holds a leadership role overseeing medical records departments, focusing on policy and compliance, while the Medical Records Coordinator handles day-to-day record management tasks. Both roles are essential in healthcare information management but differ significantly in scope and responsibilities.

What are the key skills and qualifications needed to thrive as a director medical record?

To thrive as a Director of Medical Records, you need expertise in health information management, regulatory compliance, and data privacy, typically supported by a degree in health information management or a related field and RHIA or RHIT certification. Familiarity with electronic health record (EHR) systems, coding software, and data analytics tools is crucial. Strong leadership, attention to detail, and effective communication set outstanding candidates apart in this role. These skills ensure accurate record-keeping, regulatory adherence, and seamless coordination within healthcare organizations.

What are the most commonly searched types of Medical Record jobs in Indiana?

The most popular types of Medical Record jobs in Indiana are:

What cities in Indiana are hiring for Director Medical Record jobs?

Cities in Indiana with the most Director Medical Record job openings:

Director Medical Record jobs near you

Medical Record Reviewer

Community Home Health Care & CIHC

Fort Wayne, IN

Full-time

Re-posted 3 days ago

Job description

Medical Record Reviewer

Community Home Health Care is hiring an in-office QA Nurse to oversee the accuracy, completeness, and regulatory compliance of all clinical documentation. This role is essential to ensuring our client records meet professional standards and support safe, high-quality care.

What You’ll Do

Clinical Record Audits & Documentation Review

  • Perform monthly audits of skilled nursing notes for all visiting nurses.
  • Provide direct, timely feedback to nurses on missing or incorrect documentation.
  • Re-audit records when deficiencies continue and notify the Clinical Manager as needed.
  • Audit OASIS assessments (SOC, ROC, Recertification, and Follow-Up) prior to transmission.
  • Audit at least 10% of each RN Case Manager’s charts monthly, focusing on recerts, SOC, and ROC visits.
  • Audit all documentation for newly hired RN Case Managers during their probation period.
  • Complete discharge record reviews and notify RN Case Managers when discharge charts need QA review.

Deficiency Identification & Follow-Up

  • Review charts for accuracy, completion, legal compliance, and proper care documentation.
  • Document deficiencies on the Case Conference Review form.
  • Notify nurses and department staff of deficiencies and required corrections.
  • Conduct discharge analysis when clients leave the agency.

Reporting & Collaboration

  • Track patterns and trends in documentation issues.
  • Communicate concerns and recurring problems to the Clinical Manager.
  • Support corrective action steps when needed.
  • Compile a quarterly audit report summarizing the previous three months.
  • Assist with ongoing chart review processes as assigned.

What We’re Looking For

  • Active RN license in the State of Indiana.
  • Strong understanding of home health documentation standards, Medicare/Medicaid requirements, and OASIS.
  • Excellent attention to detail and strong organizational skills.
  • Ability to communicate clearly, professionally, and constructively with nursing staff.
  • Comfortable working fully in-office in a fast-paced environment.
  • Previous QA or chart auditing experience preferred, but strong clinical documentation skills will also be considered.

Schedule & Work Environment

  • Monday–Friday schedule, in-office at the Fort Wayne location.
  • Works closely with the Clinical Manager, RN Case Managers, and field staff.
  • Computer-based role with consistent chart auditing and record review responsibilities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable federal, state, or local laws. We are committed to creating a diverse and inclusive workplace for all employees.