Medical Records

Platinum Ridge Center for Nursing & Rehabilitation - Job Title: Medical Records Clerk / CoordinatorReports To: Director of Nursing / AdministratorDepartment: Nursing / AdministrationJob Summary:The Medical Records Clerk is responsible for maintaining, organizing, and protecting all resident health information in accordance with facility policy, state, and federal regulations. This position ensures accurate, complete, and confidential documentation is kept for each resident, supporting the delivery of quality resident care.Essential Duties and Responsibilities:Maintain and update resident medical records in both paper and electronic formats.Ensure all documentation is complete, accurate, and filed promptly after care or physician visits.Protect the confidentiality of resident records and comply with HIPAA regulations.Respond to requests for medical information from authorized parties, including physicians, hospitals, and family members.Prepare charts for new admissions and maintain discharge records.Audit charts for completeness, accuracy, and compliance with regulations.Coordinate the transfer, retention, and destruction of medical records as required by policy.Assist with state and federal surveys by providing requested records or documentation.Work closely with nursing and administrative staff to ensure timely and accurate recordkeeping.Maintain logs and reports related to medical records activity.Perform other related duties as assigned.Qualifications:High school diploma or equivalent required; additional education in health information or medical office preferred.Previous experience in a healthcare or long-term care setting strongly preferred.Knowledge of medical terminology, documentation standards, and HIPAA compliance.Strong organizational skills and attention to detail.Ability to handle confidential information professionally.Proficient with electronic health records (EHR) systems and basic computer applications (Word, Excel).Physical Requirements:Frequent sitting, standing, and walking.Occasional lifting of files or boxes up to 25 lbs.Ability to handle repetitive tasks and work in a fast-paced environment.

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