Position Summary:
The Medical Records Nurse is responsible for maintaining accurate, organized, and confidential resident medical records in accordance with federal, state, and facility standards. This position ensures that all clinical documentation is complete, up to date, and compliant with regulatory requirements. The Medical Records Nurse works closely with the nursing team, physicians, and interdisciplinary staff to support quality resident care and accurate recordkeeping.
Essential Duties and Responsibilities:
Medical Record Management:
- Maintain and update resident medical records to ensure accuracy, completeness, and compliance with facility policies and legal requirements.
- Review charts for proper documentation of physician orders, assessments, progress notes, and treatment plans.
- Verify that all required signatures, dates, and forms are included in resident charts.
- File, organize, and archive medical records in accordance with retention policies.
- Prepare and audit records for new admissions, transfers, readmissions, and discharges.
- Ensure confidentiality and security of all resident health information in compliance with HIPAA regulations.
Quality Assurance and Compliance:
- Audit resident charts regularly to identify missing or incomplete documentation and follow up with appropriate staff for corrections.
- Assist in preparing documentation for state surveys, audits, and inspections.
- Collaborate with the MDS Coordinator to ensure timely completion and filing of assessment records.
- Maintain logs, reports, and other data related to resident records, physician visits, and orders.
- Ensure all physician orders are transcribed accurately and implemented promptly.
- Participate in Quality Assurance and Performance Improvement (QAPI) meetings as needed.
Communication and Coordination:
- Serve as a liaison between nursing, medical, and administrative staff to ensure smooth flow of medical information.
- Request, receive, and file information from outside providers, hospitals, and specialists.
- Respond to requests for medical records from authorized individuals in accordance with facility policy.
- Support the interdisciplinary care team by ensuring access to up-to-date resident records.
Administrative and Support Functions:
- Maintain records of resident appointments, hospitalizations, and readmissions.
- Assist with data entry, scanning, and electronic health record (EHR) management as required.
- Monitor physician visit schedules and ensure timely charting of notes and orders.
- Provide education and guidance to nursing staff regarding proper documentation standards
Qualifications:
- Current and valid Registered Nurse (RN) or Licensed Practical Nurse (LPN) license in the state of employment.
- Previous experience in medical records management, health information, or long-term care nursing preferred.
- Strong knowledge of medical terminology, documentation standards, and HIPAA regulations.
- Proficiency in electronic health record (EHR) systems.
- Excellent attention to detail, organizational, and analytical skills.
- Strong communication skills and the ability to work collaboratively with multiple departments.
- Ability to maintain confidentiality and handle sensitive information responsibly.
Physical Requirements:
- Ability to sit, stand, and move throughout the facility for extended periods.
- Must be able to lift, push, or pull up to 25 pounds occasionally.
- Visual and auditory acuity sufficient for reading charts and communicating effectively.
Work Schedule:
- Full-time position, typically Monday through Friday.
- Occasional flexibility for audits, surveys, or special projects as needed.
- Rotating OnCall for schedule
Pay: $31.00 - $34.00 per hour
Benefits:
- 403(b)
- Dental insurance
- Health insurance
- Life insurance
- Vision insurance
Work Location: In person
