Medical Records Specialist

The Medical Records Associate ensures that a complete medical records program is maintained in accordance with company standards and applicable federal, state, and local standards, guidelines, and regulations.

Key Responsibilities

• Review records on the nursing units.
• Help develop procedures to ensure records are properly assembled, coded, signed, indexed, and filed.
• Provide clerical support for the nursing management team.
• Assist in planning, developing, organizing, implementing, evaluating, and directing medical records operations.
• Collect, scan, and attach resident and patient information to the electronic medical record (EMR).
• Ensure incomplete EMRs are returned to the Nursing Department for completion.
• Gather and organize information for insurance appeals and re-certifications.
• May initiate, prepare, and help complete Medicare certifications and re-certifications.
• May notify residents, patients, and families of non-coverage for Medicare or insurance recipients.
• Complete five-day admission audits as assigned.
• Audit EMRs for completeness and report findings to leadership.
• Gather documentation needed for federal, state, and city surveys.
• Assist with procedures for collecting electronic medical records.
• Advise leadership on federal and state laws concerning medical records.
• Ensure policies and procedures for electronic medical records are followed.
• Review department policies and procedures annually and recommend changes.
• Collect and audit physician signatures and notify leadership when signatures cannot be obtained.
• Maintain confidentiality of resident and patient information.