Medical Records Clerk

Principal Responsibilities

• Manages resident health information by ensuring resident records remain accurate, complete, current, confidential, and are compliant with federal and state regulations, HIPAA, and company policies and procedures.
• Ensures accurate and current diagnostic coding to assure appropriate billing, to maximize accounts receivable and improve cash flow.
• Establishes and executes procedures in the collection, coding and indexing, and the filing/retrieving of medical records;
• Performs ICD coding; creates medical records for all new admissions.
• Must be knowledgeable on federal and state laws regarding medical records;
• Ensures resident records are maintained accurately and timely according to local, state and federal regulations;
• Performs monthly audits on: admissions, discharge and routine Quality Assurance Reviews and audits admissions, discharges, change of condition, and other pertinent records on nursing units;
• Performs routine audits of medical records upon admissions, throughout the stay, and discharge to monitor compliance with policies regarding documentation, physician visits, timeliness, etc.
• Sets incomplete records/charts back to nursing service for correction.
• Abstracts information from records as authorized/requested for insurance companies and other third-party payers.
• Ensures that registries are properly maintained for admission and discharge of residents.

Qualifications

• RHIA or RHIT credential preferred.
• Minimum of 2 years’ experience in medical records in skilled nursing facility or healthcare related field.
• Experience with ICD coding preferred.
• Knowledgeable of medical terminology, laws, and regulations, as they pertain to long term care.
• Possess effective communication skills to maintain positive relationship with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives and the community.
• Maintain neat, well-groomed and professional appearance.