Medical Record Coordinator

Job Description

Job Description

Whispering Pines Rehabilitation and Nursing Center

Medical Record Coordinator

Position Summary

The Medical Record Coordinator is responsible for maintaining, organizing, securing, and managing resident medical records in accordance with federal, state, and local regulations, facility policies, and HIPAA requirements. This position ensures the accuracy, completeness, confidentiality, and timely availability of resident health information to support quality resident care and regulatory compliance.

Essential Duties and Responsibilities

• Maintain resident medical records in both electronic and paper-based systems.
• Ensure medical records are complete, accurate, and properly filed according to facility standards.
• Review records regularly to identify and resolve documentation deficiencies, and ensure proper signatures, for example, doctor’s orders signed.
• Monitor physician orders, nursing notes, assessments, care plans, and other clinical documentation for completeness and timeliness.
• Assemble, update, thin, and archive resident charts as required.
• Manage record retention, storage, and destruction processes in compliance with regulatory requirements.
• Process requests for medical information and records while maintaining strict confidentiality and HIPAA compliance.
• Coordinate the release of medical records to authorized individuals and agencies.
• Assist with resident admissions, transfers, discharges, and readmissions by preparing and maintaining charts and appropriate forms.
• Support facility surveys, audits, inspections, and accreditation activities by providing requested records and documentation.
• Collaborate with nursing, medical staff, therapy departments, and administration to ensure accurate documentation practices.
• Monitor and maintain electronic health record (EHR) systems and troubleshoot documentation issues when appropriate.
• Educate staff on record management procedures, and confidentiality requirements.
• Ensure compliance with Centers for Medicare & Medicaid Services (CMS), HIPAA, and state regulations.
• Order office supplies and maintain medical record supplies.
• Perform other related duties as assigned.

 

 

Qualifications

Education

• High school diploma or GED required.
• Associate degree in Health Information Management, Health Administration, or related field preferred.

Experience

• Minimum of one to three years of experience in medical records, health information management, or long-term care preferred.
• Experience working in a nursing home, skilled nursing facility, or healthcare setting strongly preferred.
• Experience with electronic health record systems preferred.

Knowledge, Skills, and Abilities

• Knowledge of medical terminology and healthcare documentation standards.
• Understanding of HIPAA privacy and security regulations.
• Familiarity with long-term care regulations and medical record requirements.
• Strong organizational and time-management skills.
• Excellent attention to detail and accuracy.
• Strong written and verbal communication skills.
• Ability to work independently and manage multiple priorities.
• Proficiency in Microsoft Office applications and electronic record systems.
• Ability to maintain confidentiality and handle sensitive information professionally.

Physical Requirements

• Ability to sit, stand, walk, bend, and reach throughout the workday.
• Ability to lift and carry files and office supplies up to 25 pounds.
• Ability to operate standard office equipment, including computers, printers, copiers, and scanners.
• Ability to perform repetitive hand and keyboard movements.

Working Conditions

• Primarily works in an office environment within a nursing home or long-term care facility.
• Frequent interaction with residents, family members, healthcare professionals, and regulatory agencies.
• May be required to work occasional extended hours during surveys, audits, or special projects.

Competencies

• Attention to Detail, Confidentiality and Integrity
• Customer Service, Communication skills, organization and planning
• Teamwork and Collaboration, Problem solving
• Regulatory compliance.

 

This position plays a critical role in ensuring the integrity, accessibility, and security of resident health information while supporting the facility's commitment to quality care and regulatory compliance.

Department: Health Information Management / Medical Records
Reports To: Director of Nursing
FLSA Status: Non-Exempt

\nCompany Description

We are a 90-bed family-owned business, and our mission has and continues to be- Quality of Life through Quality of Care. Being part of our team at Whispering Pines is different than other "corporate" nursing home facilities. We provide ongoing training led by experienced and dedicated staff and medical professionals and in a dignified and comfortable environment. If you meet the qualifications below and are interested in learning more about Whispering Pines, we encourage you to apply.

Company Description

We are a 90-bed family-owned business, and our mission has and continues to be- Quality of Life through Quality of Care. Being part of our team at Whispering Pines is different than other "corporate" nursing home facilities. We provide ongoing training led by experienced and dedicated staff and medical professionals and in a dignified and comfortable environment. If you meet the qualifications below and are interested in learning more about Whispering Pines, we encourage you to apply.