Job Description

We are currently seeking a Medical Records Clerk who will be responsible for maintaining accurate, complete, and confidential resident medical records in accordance with facility policy, HIPAA regulations, and state and federal long-term care requirements. This role supports clinical, administrative, and survey functions by ensuring medical records are organized, current, and audit-ready.
Key Responsibilities
• Maintain resident medical records in compliance with HIPAA, CMS, and facility policies
• Assemble, audit, and maintain both electronic and paper medical records
• Ensure timely completion, order, and accuracy of documentation
• Monitor records for missing documentation and follow up with nursing and interdisciplinary staff
• Prepare medical records for admissions, discharges, transfers, and readmissions
• Assist with chart audits, quality assurance, and survey preparation
• Respond to record requests in accordance with release of information policies
• Maintain confidentiality and safeguard protected health information (PHI) at all times
• Collaborate with nursing, therapy, social services, and administrative staff
• Support electronic medical record (EMR) system workflows and documentation standards
Required Qualifications
• High school diploma or equivalent
• Previous experience in medical records, health information management, or healthcare administration (long-term care preferred)
• Working knowledge of HIPAA and confidentiality requirements
• Strong attention to detail and organizational skills
• Ability to manage multiple tasks and meet deadlines
Preferred Qualifications
• Experience in a long-term care or skilled nursing facility
• Familiarity with electronic medical record (EMR) systems
• Certification in Health Information Management (RHIT, RHIA) or coursework in HIM (preferred but not required)
• Experience with CMS survey processes and audits
What We Offer
• Competitive compensation based on experience
• Benefits package including medical, dental, vision, retirement, and paid time off (if applicable)
• Supportive leadership and collaborative team environment
• Stable schedule and opportunity for professional growth

We are an Equal Opportunity Employer and consider all applicants for positions without the regard to race, color, religion, sex, national origin, age, sexual orientation, marital or veteran status, or non-job related handicap or disability.