Medical Records

Legacy-Health-Services-1; Chardon (OH); On-site; USD 22,000 - 30,000; Full time

Benefits offered by this job

Competitive compensation

Benefits package

Professional growth

Supportive leadership

Job summary

Legacy Health Services in Ohio is seeking a Medical Records Clerk to maintain resident medical records, ensure accuracy, confidentiality, and compliance with HIPAA, CMS, and state/federal long-term care requirements. The role supports clinical, administrative, and survey activities by keeping documentation current and audit-ready.

You will assemble, audit, and maintain both electronic and paper records, prepare records for admissions and transfers, monitor documentation gaps, and collaborate

Qualifications

• High school diploma or equivalent.
• 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.

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.

Skills

Attention to detail

Organizational skills

Multitasking

Education

High school diploma or equivalent

Tools

EMR systems

Job description

The Medical Records Clerk is responsible for maintaining accurate, complete, and confidential resident medical records in accordance with facility policy, HIPAA regulations, and state and federal long-term care requirements. This role supports clinical, administrative, and survey functions by ensuring medical records are organized, current, and audit-ready.

Key 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

Required Qualifications

• 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

Preferred Qualifications

• 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 (preferred but not required)
• Experience with CMS survey processes and audits

What We Offer

• Competitive compensation based on experience
• 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

We are an Equal Opportunity Employer and consider all applicants for positions without the regard to race, color, religion, sex, national origin, age, sexual orientation, marital or veteran status, or non-job related handicap or disability.