Medical Records Clerk

Job Summary

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

Qualifications

• 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 pertaining to long-term care
• Effective communication skills to maintain positive relationships with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives, and the community
• RHIA or RHIT credential preferred

Responsibilities

• Manages resident health information by ensuring records remain accurate, complete, current, confidential, and compliant with federal and state regulations, HIPAA, and company policies and procedures
• Affirms accurate and current diagnostic coding to assure appropriate billing and maximize accounts receivable, improving cash flow
• Establishes and executes procedures for the collection, coding, and indexing of medical records, and the filing/retrieval of medical records; performs ICD coding; creates medical records for all new admissions
• 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
• Ensures incomplete records/charts are returned to nursing service for correction
• Abstracts information from records as authorized/requested for insurance companies and other third-party payers
• Ensures registries are properly maintained for admission and discharge of residents
• Maintains accurate tracking systems and reviews documentation to ensure center compliance
• Prepares reports for Quality Assessment and Performance Improvement (QAPI) Committee meetings; prepares reports for and participates in Triple Check Committee meetings
• Maintains and controls release of information within State, Federal, and HIPAA regulations: subpoenas in conjunction with the Director of Clinical Compliance, correspondence - including legal, access to records; protects medical records from loss or destruction by implementing a system of accountability; protects medical records from breaches of confidentiality
• Prepares and maintains a supply of charts for admission and readmission; provides nursing stations with proper chart and documentation forms; maintains daily census listing, daily room assignment listing, physician/resident list, and admission/discharge/transfer register
• Prepares requests for medical information as directed by Director of Nursing or Administrator
• Performs other duties, responsibilities, and activities as assigned