Medical Records Specialist: Coding, Compliance & Audits

OPCO Skilled Management; Prescott (AZ); Sur place; USD 42 000 - 54 000; Plein temps

Résumé du poste

Prescott Village Nursing & Rehabilitation is seeking a Medical Records Clerk to manage resident health records from admission through discharge, ensuring accuracy, confidentiality, and compliance with HIPAA, state and federal regulations.

The role requires knowledge of medical terminology, experience in medical records in healthcare settings, and attention to coding accuracy to support correct billing and quality reporting. RHIA/RHIT preferred.

Qualifications

• Minimum of 2 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.

Responsabilités

• 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.

Connaissances

Medical records management

ICD coding (preferred)

Regulatory knowledge

Communication skills

RHIA/RHIT credential (preferred)

Formation

RHIA or RHIT credential (preferred)

Description du poste

Prescott Village Nursing & Rehabilitation is seeking a Medical Records Clerk to manage resident health records from admission through discharge, ensuring accuracy, confidentiality, and compliance with HIPAA, state and federal regulations.

The role requires knowledge of medical terminology, experience in medical records in healthcare settings, and attention to coding accuracy to support correct billing and quality reporting. RHIA/RHIT preferred.