The Medical Records Clerk is responsible for maintaining resident medical records in compliance with State and Federal regulations, professional standards, and company policies. The role includes managing and ensuring the accuracy of medical resident records from pre-admission through post-discharge.

Responsibilities include:

Managing resident health information to ensure accuracy, completeness, currency, confidentiality, and compliance with federal, state, and company policies including HIPAA.
Performing ICD coding and ensuring accurate diagnostic coding to support appropriate billing and maximize accounts receivables.
Establishing and executing procedures for collection, coding, indexing, filing, and retrieving medical records.
Performing monthly audits on admissions, discharges, and quality assurance.
Ensuring incomplete records are corrected promptly in collaboration with nursing services.
Abstracting information from records for insurance and third-party payers as authorized.
Maintaining registries and accurate tracking systems for resident admissions and discharges.
Preparing reports for Quality Assessment and Performance Improvement (QAPI) and Triple Check Committee meetings.
Controlling release of information in accordance with State, Federal, and HIPAA regulations.
Protecting medical records against loss, destruction, or breaches of confidentiality.
Supporting nursing stations with documentation forms and maintaining census and admission/discharge records.
Preparing medical information requests as directed.

Qualifications:

Minimum 2 years’ experience in medical records administration within skilled nursing or healthcare.
Experience with ICD coding preferred.
Knowledge of medical terminology, laws, and regulations relevant to long-term care.
Effective communication skills to maintain positive relationships with residents, families, staff, and external representatives.
RHIA or RHIT credential preferred.