About This Role
Maintaining accurate, complete, and confidential resident medical records is the primary responsibility of this role, ensuring compliance with facility policy, HIPAA regulations, and state and federal long-term care requirements. This position supports clinical, administrative, and survey functions by keeping medical records organized, current, and audit-ready.
Responsibilities
- Maintain resident medical records in compliance with HIPAA, CMS, and facility policies
- Assemble, audit, and maintain both electronic and paper medical records
- Ensure timely completion, order, and accuracy of documentation
- Monitor records for missing documentation and follow up with nursing and interdisciplinary staff
- Prepare medical records for admissions, discharges, transfers, and readmissions
- Assist with chart audits, quality assurance, and survey preparation
- Respond to record requests in accordance with release of information policies
- Maintain confidentiality and safeguard protected health information (PHI) at all times
- Collaborate with nursing, therapy, social services, and administrative staff
- Support electronic medical record (EMR) system workflows and documentation standards
Requirements
- High school diploma or equivalent
- Previous experience in medical records, health information management, or healthcare administration (long-term care preferred)
- Working knowledge of HIPAA and confidentiality requirements
- Strong attention to detail and organizational skills
- Ability to manage multiple tasks and meet deadlines
Nice to have:
- Experience in a long-term care or skilled nursing facility
- Familiarity with electronic medical record (EMR) systems
- Certification in Health Information Management (RHIT, RHIA) or coursework in HIM
- Experience with CMS survey processes and audits
Benefits
- Benefits package including medical, dental, vision, retirement, and paid time off (if applicable)
- Supportive leadership and collaborative team environment
- Stable schedule and opportunity for professional growth
