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

Candidates should have a minimum of 2 years' experience in medical records within a skilled nursing facility or healthcare-related field. Experience with ICD coding is preferred. Knowledge of medical terminology, laws, and regulations pertaining to long-term care is required. Effective communication skills are essential to maintain positive relationships with residents, families, staff, physicians, consultants, providers, and governmental agencies. RHIA or RHIT certification is preferred.

Key responsibilities include managing resident health information to ensure accuracy, completeness, currency, confidentiality, and compliance with federal/state regulations and HIPAA. The role involves accurate diagnostic coding to support appropriate billing, establishing procedures for collection, coding, indexing, filing, and retrieval of medical records, and performing monthly audits of admissions, discharges, and quality assurance. The clerk ensures incomplete records are returned for correction and abstracts information for insurance and third-party payers as authorized.

Additional duties include maintaining registries for admissions and discharges, preparing reports for Quality Assessment and Performance Improvement (QAPI) and Triple Check Committees, controlling release of information per regulations, protecting medical record confidentiality, and managing chart supplies and census records.