Medical Records Specialist

Job Description

Job Description

Description:

We are looking for a talented LPN to join our team as a Medical Records Specialist!

In this role, you will play an important part in ensuring our residents' medical records are accurate, complete, secure, and maintained in compliance with Federal, State, and local regulations , as well as company policies and procedures.

• Provide daily clinical stand-up reports, including past-due forms, clinical alerts, orders, admissions, discharges, and other important updates.
• Compile, organize, and maintain resident medical records and enter information into the appropriate software systems.
• Collect and update information from nursing staff, physicians, and other healthcare professionals.
• Monitor and audit medical records for completeness, accuracy, and compliance.
• Provide resident information to authorized personnel while maintaining HIPAA compliance.
• Process transfer and discharge records and complete required discharge audits.
• Maintain appropriate records for former residents according to company policy.
• Assist with Nursing Department administrative activities, audits, and education.
• Travel to hospitals, physician offices, and other locations when documentation or signatures are needed.
• Complete daily audits of skilled care documentation and changes in condition.
• Participate in QI and Infection Control functions as directed.
• Complete routine daily, weekly, monthly, and quarterly medical record audits.
• Participate in PDPM Committee responsibilities.
• Resolve and clarify conflicting, missing, or unclear codes and diagnoses by communicating with physicians and other appropriate professionals.
• Prepare statistical and narrative reports for physicians, the facility, company leadership, and state or federal agencies.
• Maintain hard-copy records for use during power outages and emergency situations.
• Compile census, demographic, and medical data as requested.
• Oversee appropriate use and documentation within software systems and provide audits and education as needed.
• Update CNA tasks daily based on orders and information discussed during clinical meetings.
• Trigger required forms according to the MDS schedule and forms table.
• Serve as the facility's HIPAA Privacy Officer , working alongside the Administrator and HIM to support compliance with applicable regulations, policies, procedures, forms, and logs.

• Active LPN license
• Long-term care experience preferred
• Strong organizational and attention-to-detail skills
• Compassion and accountability
• Trustworthiness and honesty
• Comfortable adapting to change
• Strong communication and teamwork skills
• A willingness to learn, grow, and make a difference
• Most importantly, a genuine love for serving others and caring for our residents

If you're an LPN looking for an opportunity to use your clinical knowledge in a role where organization, accuracy, and resident care all come together , we'd love to have you join our team!