Medical Records RN/LPN

About the Role

Responsible for maintaining resident medical records in accordance with State and Federal regulations, professional standard of practice, and company policy and procedure. 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 and procedures.
• Ensures accurate and current diagnostic coding to assure appropriate billing, maximize accounts receivable, and improve cash flow.
• Establishes and executes procedures for the collection, coding, indexing, filing, and retrieving of medical records.
• Performs ICD coding and creates medical records for all new admissions.
• Ensures knowledge of and compliance with federal and state laws regarding medical records.
• Maintains resident records accurately and timely according to local, state, and federal regulations.
• Performs monthly audits on admissions, discharges, and routine Quality Assurance.
• Ensures registries are properly maintained for admission and discharge of residents.
• Protects medical records from breaches of confidentiality.

Requirements

• Minimum of 2 years’ experience in medical records in a skilled nursing facility or healthcare-related field.
• Must be a Registered Nurse or Licensed Practical Nurse.
• 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 relationships with residents, families, staff, physicians, consultants, providers, governmental agencies, their representatives, and the community.
• RHIA or RHIT credential preferred.

Benefits

• 401K
• Annual evaluations
• Dental insurance
• Disability insurance
• Electronic documentation
• Employee appreciation events
• Health insurance
• Life insurance
• Modified Comp
• Paid time off
• Tuition reimbursement
• Vision insurance