Medical Records Specialist – Long-Term Care & Compliance

Mullican Wellness & Rehabilitation; Savoy (TX); On-site; USD 40,000 - 60,000; Full time

Job summary

Mullican Wellness & Rehabilitation is seeking a Medical Records Clerk to maintain resident medical records in accordance with state and federal regulations, professional standards, and company policy. You will manage records from pre-admission to post-discharge, ensuring accuracy, confidentiality, and compliance with HIPAA and governing laws.

The role requires at least 2 years of medical records experience in a skilled nursing or healthcare setting, with preferred ICD coding familiarity and

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.

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.
• 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.

Skills

Medical records management

ICD coding

HIPAA compliance

Communication skills

Education

RHIA/RHIT certification

Job description

Mullican Wellness & Rehabilitation is seeking a Medical Records Clerk to maintain resident medical records in accordance with state and federal regulations, professional standards, and company policy. You will manage records from pre-admission to post-discharge, ensuring accuracy, confidentiality, and compliance with HIPAA and governing laws.

The role requires at least 2 years of medical records experience in a skilled nursing or healthcare setting, with preferred ICD coding familiarity and