Medical Records Supervisor/Director with 20 plus years experience in health records management and regulatory compliance at Skilled Nursing Facility. Demonstrated success in auditing procedures and training staff, ensuring patient confidentiality and accuracy in medical records. Committed to improving healthcare documentation systems to enhance patient care outcomes.
Overview
21
21
years of professional experience
Work History
Medical Records Supervisor
Laguna Hills Health & Rehabilitation Center
Laguna Hills
12.2019 - Current
Oversaw the maintenance of electronic health records systems.
Coordinated with providers on any changes needed in order to meet accreditation requirements.
Supervised staff responsible for the maintenance of patient records to ensure accuracy and compliance with HIPAA regulations.
Conducted regular and systems audits of medical records to ensure completeness and accuracy.
Organized medical charts by assigning codes to diagnoses and procedures using ICD-10-CM coding system.
Entered data into electronic health record systems to ensure accuracy and completeness of medical records.
Developed and maintained procedures for medical records management, including storage, retrieval, retention and destruction of medical records.
Returned incomplete records and charts to appropriate personnel for correction.
Managed well-organized system of closed and open medical records with ready availability to interdisciplinary personnel.
Medical Records Resource Staff
Cambridge Healthcare Management
Buena Park
02.2015 - 12.2019
Reviewed medical records to ensure accuracy and completeness.
Provided training on the use of electronic health record systems to staff members.
Traveled to different clinical sites to review patient charts and check for their completeness and compliance to standards.
Assisted in auditing medical records for compliance with legal and regulatory standards.
Implemented updates and improvements to electronic health records systems as directed.
Medical Records Director
Anaheim Crest Nursing Center
Anaheim
02.2004 - 02.2015
Conducted audits of medical records to identify areas needing improvement or corrective action.
Reviewed discharges and other records on nursing units for compliance with procedures.
Managed well-organized system of closed and open medical records with ready availability to interdisciplinary personnel.
Managed release of information requests and identified requestors as patient, relation or provider.
Observed confidentiality and safeguarded all patient-related information.
Education
Vocational - Midwifery
Our Lady of Fatima University
Manila Philippines
03-1990
Skills
ICD-10-CM coding
Data entry
Electronic health records
Medical records management
Auditing procedures
Regulatory compliance
Staff training
Patient confidentiality assurance
Healthcare compliance
Electronic health records management
Records organization and maintenance
Accomplishments
Recognized Employee of the Month while working at Anaheim Crest Nursing Center and at Laguna Hills Health and Rehabilitation Center