Director of Medical Records (HIM/ Coding Required)
Cypress Cove Care Center
Crystal River, FL
Director of Medical Records (HIM / Coding Required)
Position Summary
Key Responsibilities
Qualifications
What We Offer
Cypress Cove Care Center
700 SE Dr. Martin Luther King Jr. Avenue
Crystal River, FL 34429
Skilled Nursing Facility
Full-Time | Day Shift
Now Hiring: Experienced Medical Records Director with Strong Coding Background
Cypress Cove Care Center is seeking a highly skilled Director of Medical Records with proven medical coding experience to oversee Health Information Management operations in our well-established skilled nursing facility.
This role requires a detail-driven professional with a strong understanding of ICD-10 coding, clinical documentation standards, and long-term care regulatory compliance. Coding expertise is essential to ensure accurate reimbursement, audit readiness, and documentation integrity.
The Director of Medical Records is responsible for managing all aspects of health information systems, clinical record accuracy, regulatory compliance, and medical coding oversight. This position works closely with nursing leadership, MDS, therapy, and administration to support documentation accuracy, survey preparedness, and reimbursement compliance.
- Oversee daily operations of the Medical Records / HIM department
- Ensure accurate ICD-10 coding and proper assignment in accordance with CMS and payer guidelines
- Review clinical documentation to validate coding accuracy and completeness
- Conduct routine chart audits to support reimbursement accuracy and survey readiness
- Monitor compliance with HIPAA, documentation standards, and state/federal regulations
- Maintain resident record integrity, retention, and release-of-information processes
- Collaborate with MDS and clinical leadership to support PDPM documentation requirements
- Educate clinical staff on documentation and coding best practices
- Prepare records and reports for audits, surveys, and quality assurance initiatives
- Safeguard all protected health information
- Certified Coding credential preferred (CCA, CCS, RHIT, or RHIA)
- Strong working knowledge of ICD-10 coding guidelines
- Prior experience in a skilled nursing facility (SNF) or long-term care setting required
- Experience auditing clinical documentation for accuracy and compliance
- Thorough understanding of CMS regulations, HIPAA, and long-term care documentation standards
- Strong analytical and organizational skills
- Ability to work independently and collaborate with interdisciplinary teams
- RHIT or RHIA strongly preferred
- Experience with electronic medical record systems in long-term care
- Knowledge of PDPM reimbursement structure
- Competitive compensation with Daily Pay option available
- Full-time, stable day-shift schedule
- Comprehensive benefits package including:
- Medical, Dental, and Vision Insurance
- Paid Time Off (PTO)
- 401(k) with Employer Contributions
- Company-Paid Life Insurance
- Supportive leadership team
- Long-term career growth opportunities
If you are an experienced health information professional with strong coding expertise and a passion for documentation accuracy and compliance, we encourage you to apply today.
Job Duty Disclaimer
This job description is not intended to be all-inclusive. Duties and responsibilities may be modified to meet resident, regulatory, and operational needs.
Equal Opportunity Employer
Cypress Cove Care Center is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristic.
All background screenings will be completed through:
https://info.flclearinghouse.com
#INDCC123
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