Medical Records / Central Supply

OPCO Skilled Management; Fort Worth (TX); On-site; USD 45,000 - 65,000; Full time

Benefits offered by this job

401(k)

Dental insurance

Health insurance

Life insurance

Vision insurance

Job summary

Fort Worth Wellness and Rehabilitation Center is seeking a skilled Medical Records professional to manage resident records from pre-admission through post-discharge, ensuring accuracy and confidentiality in compliance with state and federal regulations. This role focuses on ICD coding, documentation integrity, and timely reporting to support quality care and regulatory requirements.

The candidate should have at least 3 years of medical records experience in a skilled nursing or healthcare

Qualifications

• Minimum of 3 years’ experience in medical records in skilled nursing facility or healthcare related field.
• Experience with ICD coding preferred.
• Knowledgeable of medical terminology, laws, and regulations pertaining to long-term care.
• Possess effective communication skills to maintain relationships with residents, families, staff, physicians, consultants, providers, and governmental agencies.
• RHIA or RHIT credential preferred.

Responsibilities

• Maintain resident medical records accurately and confidentially per state and federal regulations.
• Ensure accurate diagnostic coding to maximize billing and cash flow.
• Perform monthly audits on admissions, discharges, and QA processes.
• Abstract information for third-party payers and maintain registries for admissions/discharges.
• Prepare reports for QAPI and Triple Check Committees.
• Protect records from breaches and manage release of information.

Skills

Communication skills

Attention to detail

HIPAA compliance understanding

Education

RHIA/RHIT credentials preferred

Tools

ICD coding

Job description

Job type: Full Time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Vision insurance

Your Job Summary

Central Supply/ Medical Records will be responsible for maintaining resident medical records in accordance with State and Federal regulations, professional standard of practice and company policy and procedure. Responsible for ensuring the management and accuracy of medical resident records from pre-admission to post discharge.

QUALIFICATIONS

• Minimum of 3 years’ experience in medical records in skilled nursing facility or healthcare related field.
• Experience with ICD coding preferred.
• Knowledgeable of medical terminology, laws, and regulations, as they pertain to long term care.
• Possess effective communication skills to maintain positive relationship with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives and the community.
• RHIA or RHIT credential preferred.

RESPONSIBILITIES

Manages resident health information by ensuring resident records remain accurate, complete, current, confidential, and are compliant with federal and state regulations, HIPAA, and company policies and procedures.

• Ensures accurate and current diagnostic coding to assure appropriate billing, to maximize accounts receiving and improve cash flow.
• Establishes and executes procedures in the collection, coding and indexing, and the filing/retrieving of medical records; Performs ICD coding; creates medical records for all new admissions.
• Must be knowledgeable on federal and state laws regarding medical records; Ensures resident records are maintained accurately and timely according to local, state and federal regulations; Performs monthly audits on: admissions, discharge and routine Quality Assurance
• Ensures that incomplete records/charts are returned to nursing service for correction.
• Abstracts information from records as authorized/requested for insurance companies and other third-party payers.
• Ensures that registries are properly maintained for admission and discharge of residents.
• Maintains accurate tracking systems and reviews documentation to ensure center compliance.
• Prepares reports for Quality Assessment and Performance Improvement (QAPI) Committee meetings; Prepares reports for and participates in Triple Check Committee meetings.
• Maintains and controls release of information within State, Federal and HIPPA regulations: Subpoena in conjunction with the Director of Clinical Compliance, Correspondence – including legal, Access to Records; Protects medical records from loss or destruction by implementing a system of accountability.
• Protects medical records from breaches of confidentiality.
• Prepares and maintains a supply of charts for admission and readmission; Provides nursing stations with proper chart and documentation forms; Maintains daily census listing, daily room assignment listing, physician/resident list, and admission/discharge/transfer register.
• Prepares requests for medical information as directed by Director of Nursing or Administrator.
• Other duties, responsibilities and activities may change or assigned at any time with or without notice.

Fort Worth Wellness and Rehabilitation Center provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.