Dallas - TX Full Time, Part Time 2 months ago


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.


  • Minimum of 2 years’ experience in medical records in skilled nursing facility or healthcare related field.
  • 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.


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 incomplete records/charts are returned to nursing service for correction. • Abstracts information from records as authorized/requested for insurance companies and other third-party payers.

  • Ensures that registries are properly maintained for admission and discharge of residents.
  • Maintains accurate tracking systems and reviews documentation to ensure center compliance.
  • Prepares reports for Quality Assessment and Performance Improvement (QAPI) Committee meetings; Prepares reports for and participates in Triple Check Committee meetings.
  • Maintains and controls release of information within State, Federal and HIPPA regulations: Subpoena in conjunction with the Director of Clinical Compliance, Correspondence – including legal, Access to Records; Protects medical records from loss or destruction by implementing a system of accountability.
  • Protects medical records from breaches of confidentiality.
  • Prepares and maintains a supply of charts for admission and readmission; Provides nursing stations with proper chart and documentation forms; Maintains daily census listing, daily room assignment listing, physician/resident list, and admission/discharge/transfer register.

• Prepares requests for medical information as directed by Director of Nursing or Administrator • Other duties, responsibilities and activities may change or assigned at any time with or without notice.

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