Overview:
The Medical Records Specialist is responsible for maintaining accurate, organized, and compliant medical records in accordance with company policies, OBRA guidelines, and applicable state regulatory standards. This role manages electronic medical records (EMR), physician order documentation, chart audits, records requests, and medical record retention processes while supporting regulatory compliance and documentation accuracy. The Medical Records Specialist serves as a key resource for medical records management, healthcare documentation workflow, and quality assurance activities, and may provide administrative and clinical support to the nursing department as needed.
Responsibilities:
- Maintain medical record files and scan documentation into the electronic medical record (EMR) system in accordance with company policies and regulatory requirements.
- Accurately scan, file, and maintain patient information within individual medical records.
- Manage inventory of forms and supplies for nursing stations and prepare spend-down documentation for leadership review.
- Prepare correspondence and administrative documentation related to medical records operations.
- Enter physician orders, patient weights, and other clinical information into clinical software systems when applicable.
- Submit physician orders and interim orders for physician signature and ensure timely receipt of required electronic signatures.
- Conduct chart audits and medical records reviews to identify documentation deficiencies, compliance concerns, and incomplete records, and communicate findings to physicians and clinical leadership.
- Prepare and distribute daily, weekly, and monthly audit reports for review, correction, and completion of required documentation.
- Process medical records requests, maintain records-release logs, prepare documentation for release of information, and coordinate records requests with legal counsel when required.
- Ensure discharge records, discharge summaries, assessments, and related documentation are completed and maintained according to established medical records procedures.
- Participate in quality assurance activities, maintain compliance with clinical policies and procedures, and support patient record management initiatives.
- Attend required training and perform additional duties as assigned to support medical records operations and organizational objectives.
- Maintain confidentiality of patient information in accordance with HIPAA and organizational policies.
- Participate in Quality Assurance and Performance Improvement (QAPI) activities as assigned.
- Support agency readiness for audits, surveys, payer reviews, and regulatory inspections.
Qualifications:
- Registered Health Information Technician or high school graduate (or equivalent).
- Minimum of one year of medical records experience in a long-term care setting preferred.
- Computer literacy required.
- Knowledge of HomeCare HomeBase (HCHB) preferred.
- Ability to read, write, and communicate effectively in English.
Benefits/EEO:
What We Offer You
- Competitive Wages
- 401k with match
- Medical, Dental, Vision & Supplemental Insurance
- Vacation, Sick, Personal Holiday & Paid Holidays
- Short-Term Disability
- Life Insurance
- Tuition & CEU Reimbursement
- Rewards & Recognition Program
EEOC
We are an Equal Opportunity Employer. We offer an excellent benefit plan to include 401(k) with match, CEU reimbursement, vacation, sick time, holidays, medical, dental, and supplemental insurance plans, as well as a highly competitive compensation package.