Medical Records RN/LPN

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.

GENERAL DUTIES

• 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 registries are properly maintained for admission and discharge of residents.
• Protects medical records from breaches of confidentiality.

QUALIFICATIONS

• Minimum of 2 years’ experience in medical records in skilled nursing facility or healthcare related field.
• Must be a Registered Nurse or Licensed Practical Nurse
• 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.

BENEFITS

• 401K
• Annual evaluations
• Dental insurance
• Disability insurance
• Electronic documentation
• Employee appreciation events
• Health insurance
• Life insurance
• Modified Comp
• Paid time off
• Tuition reimbursement
• Vision insurance