Medical Records Coordinator

Position Summary

Christian Care is seeking a Medical Records Coordinator. The Medical Records Coordinator organizes, maintains, audits, and protects resident health records for the long-term-care facility. This position ensures that electronic and paper records are accurate, complete, confidential, readily accessible, and maintained according to facility policies and applicable federal and Indiana requirements. 

The coordinator works closely with nursing, physicians, therapy, pharmacy, billing, admissions, and other departments to obtain missing documentation and support survey readiness.

Position Details: Competitive pay based on experience, qualifications, and applicable licensure. 

• Fulltime
• Monday - Friday
• paid holidays, 403b
• Insurance starts on day one. 
• PTO available after 90 days of employment ( PTO exchange)
• Perfect attendance bonuses 

Essential Duties and Responsibilities

• Maintain active and discharged resident records in the electronic medical record system.
• Review new-admission records for completeness, accuracy, required consents, physician orders, diagnoses, and supporting documentation.
• Perform routine audits of resident records and promptly communicate deficiencies to the appropriate department.
• Track physician signatures, verbal orders, histories and physicals, Medicare certifications and recertifications, and other time-sensitive documentation.
• Assemble, organize, thin, scan, index, archive, and retrieve medical records according to facility procedures.
• Process authorized requests for medical information, subpoenas, insurance documentation, and continuity-of-care records.
• Verify that appropriate authorization is obtained before releasing protected health information.
• Maintain release-of-information logs and document all disclosures.
• Protect resident confidentiality and follow HIPAA, facility privacy, and information-security requirements.
• Assist nursing and interdisciplinary staff with electronic medical record documentation and workflow questions.
• Monitor documentation reports and follow up on incomplete, late, unsigned, or inconsistent entries.
• Support quality-assurance activities, audits, investigations, legal requests, and regulatory surveys.
• Prepare discharged records for completion, retention, storage, or approved destruction.
• Maintain accurate census, admission, discharge, transfer, and medical-record tracking information.
• Coordinate with physicians, hospitals, hospice providers, pharmacies, laboratories, and other healthcare partners when records are needed.
• Report suspected privacy breaches, altered records, missing documentation, or other compliance concerns immediately.
• Participate in staff education concerning documentation, confidentiality, and medical-record procedures.
• Follow infection-control, safety, resident-rights, and emergency-preparedness policies.
• Perform other related duties assigned by the Administrator or Director of Nursing.

Required Qualifications

• High school diploma or equivalent.
• At least two years of medical-records experience in a skilled-nursing or long-term-care setting.
• Working knowledge of medical terminology, medical-record organization, HIPAA, and documentation practices.
• Experience conducting chart audits and resolving documentation deficiencies.
• Proficiency with electronic medical record systems and Microsoft Office.
• Strong organizational skills and close attention to accuracy.
• Ability to prioritize multiple deadlines and handle confidential information appropriately.
• Professional communication skills and the ability to work effectively with clinical and administrative personnel.

Employment is contingent based on a clear background check and a negative drug screen.