Medical Records Coordinator | CNA (72587)

About the Role

The Medical Records Coordinator is responsible for the accurate maintenance, coordination, confidentiality and regulatory compliance of resident medical records and health information systems. This position supports clinical care, reimbursement integrity and survey readiness by ensuring medical records meet all federal, state, and facility requirements. This position reports directly to the Facility Administrator.

Responsibilities

Medical Records Coordination & Compliance

• Coordinate and maintain resident medical records in compliance with HIPAA and all federal, state and local regulations
• Initiate, assemble, audit, thin and close medical records per facility policy
• Audit electronic health record (EHR) documentation for completeness, accuracy and timeliness
• Track physician certifications and recertifications required for skilled nursing and rehabilitation services
• Coordinate with hospital, admissions, and clinical staff to ensure appropriate ICD-10 coding to support PDPM and other reimbursement methodologies
• Identify incomplete or missing documentation and return records to the appropriate departments for correction
• Serve as a point of contact for surveys, audits, legal requests and external reviews related to medical records
• Collaborate with clinical consultants, nursing leadership and administration to maintain record accuracy and compliance

Administrative & Record Management

• Respond to authorized medical record requests from insurance companies, Medicare, Medicaid, VA, healthcare providers and legal entities in accordance with HIPAA requirements
• Maintain tracking logs of all authorized disclosures of protected health information (PHI)
• Provide complete and certified copies of medical records within required timeframes
• Ensure medical records are properly signed, indexed, coded, filed and stored
• Set up medical charts and EHR profiles for all new admissions
• Batch, input, retrieve and maintain resident demographic and clinical information
• Ensure medical records removed from the department are properly signed out and returned
• Transcribe physician documentation as necessary
• Facilitate secure transport, retrieval and delivery of medical records throughout the facility
• Assist with coordination of translated medical and admission paperwork

Certified Nurse Aide duties include helping with weekly weights for residents and occasional assistance with residents if needed.

Requirements

Education

• High school diploma or equivalent
• Texas Certified Nurse Aide Preferred
• Education in Health Information Management or related field (preferred)

Experience | Skills | Knowledge

• Knowledgeable in computers, data retrieval, input and output functions
• Strong organizational skills with exceptional attention to detail
• Ability to handle confidential information with professionalism and discretion
• Experience in medical records, health information management or long-term care (preferred)
• Working knowledge of HIPAA privacy and security regulations
• Familiarity with EHR systems and medical record auditing
• Knowledge of PDPM and ICD-10 coding

Physical | Sensory Requirements

• Able to push, pull, move and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move and/or carry such weight a minimum distance of 50 feet
• Sitting, standing and bending to pick up items
• May be necessary to assist in the evacuation of residents during emergency situations

Benefits

• Medical, Dental, and Vision insurance
• Basic Company Paid Life insurance
• Long Term Disability
• Voluntary Life Insurance for the Employee, Employee Spouse and Employee Children
• Short Term Disability, Cancer, Critical Illness, Accidental and Universal Life insurance options
• Employee Referral Bonus Potential Program
• Daily Pay
• Tuition Reimbursement
• Paid Time Off