Medical Records Clerk

About the Role

The Medical Records Clerk is responsible for maintaining resident medical records in accordance with State and Federal regulations, professional standards of practice, and company policy and procedure. This role ensures the management and accuracy of medical resident records from pre-admission to post-discharge.

Responsibilities

• Manages resident health information by ensuring records remain accurate, complete, current, confidential, and compliant with federal and state regulations, HIPAA, and company policies.
• Ensures accurate and current diagnostic coding to support appropriate billing, maximize accounts receivable, and improve cash flow.
• Establishes and executes procedures for collecting, coding, indexing, filing, and retrieving medical records.
• Performs ICD coding and creates medical records for all new admissions.
• Maintains knowledge of federal and state laws regarding medical records and ensures compliance.
• Conducts monthly audits on admissions, discharges, and routine Quality Assurance.
• Ensures incomplete records/charts are returned to nursing service for correction.
• Abstracts information from records as authorized for insurance companies and third-party payers.
• Maintains accurate tracking systems and reviews documentation to ensure center compliance.
• Prepares reports for Quality Assessment and Performance Improvement (QAPI) Committee meetings and participates in Triple Check Committee meetings.
• Controls the release of information within State, Federal, and HIPAA regulations, including handling subpoenas and legal correspondence.
• Protects medical records from loss, destruction, or breaches of confidentiality by implementing accountability systems.
• Prepares and maintains charts for admissions and readmissions, and supplies nursing stations with proper documentation forms.
• Maintains daily census listings, room assignments, physician/resident lists, and admission/discharge/transfer registers.
• Prepares requests for medical information as directed by the Director of Nursing or Administrator.
• Performs other duties, responsibilities, and activities as assigned.

Requirements

• Minimum of 2 years’ experience in medical records in a skilled nursing facility or healthcare-related field.
• Experience with ICD coding preferred.
• Knowledgeable of medical terminology, laws, and regulations pertaining to long-term care.
• Effective communication skills to maintain positive relationships with residents, families, staff, physicians, consultants, providers, governmental agencies, and the community.

Qualifications

• RHIA or RHIT credential preferred.