Medical Records Specialist – Skilled Nursing & ICD Coding

Opco-Skilled-Management-; Fort Worth (TX); On-site; USD 42,000 - 62,000; Full time

Benefits offered by this job

401(k)

Dental insurance

Health insurance

Life insurance

Vision insurance

Job summary

Opco-Skilled-Management- seeks a Central Supply/Medical Records professional to maintain resident medical records in a skilled nursing facility in Fort Worth, TX. You will ensure accuracy, confidentiality, and regulatory compliance from pre-admission through discharge.

The role requires at least 3 years in medical records, ICD coding experience is a plus, and familiarity with long-term care regulations. RHIA/RHIT credentials are preferred; strong communication is essential.

Qualifications

• 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 positive relationships with residents, families, staff, physicians, consultants, providers, and governmental agencies.
• RHIA or RHIT credential preferred.

Responsibilities

• Manages resident health information by ensuring resident records remain accurate, complete, current, confidential, and 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.

Skills

Effective communication

Attention to detail

HIPAA knowledge

Education

RHIA or RHIT credential preferred

Job description

Opco-Skilled-Management- seeks a Central Supply/Medical Records professional to maintain resident medical records in a skilled nursing facility in Fort Worth, TX. You will ensure accuracy, confidentiality, and regulatory compliance from pre-admission through discharge.

The role requires at least 3 years in medical records, ICD coding experience is a plus, and familiarity with long-term care regulations. RHIA/RHIT credentials are preferred; strong communication is essential.