Medical Records Specialist

We are searching for a talented nurse to join our clinical team as the Medical Records Specialist. A Medical Records Specialist is responsible for maintaining all medical records in accordance with Federal, State, local regulations, and company policy and procedure.

What do we do? Connect People 2 Life!

How do we Connect People 2 Life? Through reconnecting them to the relationships that make life full: S(Sprint) N(Nature) O(Others) W(Work) S(Self)! We make it SNOW every day!

Duties and Responsibilities

• Provide daily reports during clinical stand up to include past due forms, clinical alerts, orders, admissions, discharges, etc

• Compile and set up residents’ medical records and enter data into software system.

• Collect information from nursing staff, physicians, and other sources and update data in software and hard copy needed.

• Monitor and audit records for completeness and accuracy in accordance with company policies and state regulations.

• Provide resident information to the approved personnel as needed.

• Process transfer or discharge record and discharge auditing.

• Maintain appropriate records on former residents, storage per company policy.

• Assist in coordinating Nursing Department activities to include administrative support and audits and education.

• Run errands that may include travel to hospitals and doctor offices for documentation needing signatures.

• Daily auditing of skilled care documentation as well as changes in condition for all records.

• QI and IC functions as directed.

• Routine daily, weekly, monthly and quarterly medical records audits.

• PDPM Committee meeting member responsibilities.

• Resolve/clarify codes and diagnoses with conflicting, missing or unclear information and consult with doctors or others to get information.

• Prepare statistical reports or narrative reports for physician, facility, company, or state agency (vital records, death report, infection reporting).

• Prepare hard copy of records for use during power failures and emergency situations as per policy.

• Compile census, demographic or medical data as requested by facility, company, or state/federal agency.

• Oversee appropriate use and documentation in software and provide audits/education as needed or directed.

• Update CNA task daily with changes as they occur based on orders and information discussed during the clinical meeting.

• Trigger forms based on MDS schedule and forms table.

• HIPAA Privacy Officer responsible for the facility’s HIPAA compliance, in conjunction with the Administrator and HIM, including but not limited to all regulations, laws, policies and procedures, forms and logs

Qualifications: Active LPN, long-term care experience, Compassion, accountability, not scared of change, trustworthiness, ready to make a difference, honesty, love for your grandparents.

EEO Statement

This company does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.”