The Medical Records Specialist will be responsible for maintaining accurate and confidential medical records for our residents, ensuring compliance with regulatory standards and facilitating the efficient flow of information within the facility. This position requires strong organizational skills, attention to detail, and a commitment to maintaining the integrity and confidentiality of medical records.
Schedule: Full-Time, Weekdays, Monday - Friday, 8AM - 5PM
Primary Responsibilities and Duties:
- Collect, organize, and maintain medical records for all residents, ensuring completeness, accuracy, and compliance with regulatory requirements.
- Review incoming documentation, including physician orders, progress notes, lab results, and diagnostic reports, and file records in accordance with established procedures.
- Create new medical records for newly admitted residents, inputting demographic information, insurance details, and other relevant data into electronic health record systems.
- Retrieve medical records as requested by authorized healthcare providers, staff members, regulatory agencies, and legal representatives, ensuring timely and accurate record retrieval.
- Prepare medical records for external audits, surveys, and reviews by regulatory agencies, ensuring compliance with documentation standards and facilitating the resolution of any deficiencies.
- Maintain the confidentiality and security of medical records, adhering to HIPAA regulations and facility polices governing access, disclosure, and release of protected health information.
- Assist with the scanning, indexing, and electronic filing of paper documents into electronic health record systems, ensuring accuracy and completeness of electronic records.
- Perform regular audits and quality checks of medical records to identify discrepancies, errors, or missing documentation, and take corrective action as needed.
- Provide support and assistance to healthcare providers, nursing staff and administrative personnel regarding medical record documentation, retrieval, and interpretation.
- Assist with the coordination of medical record transfers for residents who transfer to other healthcare facilities or agencies, ensuring continuity of care and accurate record transmission.
- Collaborate with team members including nurses, physicians, therapists, and social workers to facilitate communication and information sharing related to resident care.
- Perform all other duties assigned.
- Central Supply - Ordering and stocking medical supplies.
