Medical Records Clerk

Medical Records Clerk

OPCO Skilled Management is hiring a Medical Records Clerk to maintain resident medical records in accordance with State and Federal regulations, professional standards, and company policy and procedure. The role ensures accuracy and completeness of records from pre‑admission to post‑discharge.

• Minimum of 2 years’ experience in medical records in a skilled nursing facility or related healthcare field.
• Experience with ICD coding preferred.
• Knowledge of medical terminology, laws, and regulations pertaining to long term care.
• Effective communication skills to maintain positive relationships with residents, families, staff, physicians, consultants, providers, and government agencies.
• RHIA or RHIT credential preferred.

• Manage resident health information, ensuring records remain accurate, complete, confidential, and compliant with federal and state regulations, HIPAA, and company policies.
• Ensure accurate and current diagnostic coding to maximize billing and improve cash flow.
• Establish and execute procedures for collection, coding, indexing, filing, and retrieving medical records; perform ICD coding; create records for new admissions.
• Ensure record maintenance meets federal and state law requirements; perform monthly audits of admissions, discharges, and routine quality assurance.
• Return incomplete records to the nursing service for correction.
• Abstract information from records for insurance companies and other third‑party payers.
• Maintain registries for admissions and discharges.
• Maintain tracking systems and review documentation for compliance.
• Prepare reports for Quality Assessment and Performance Improvement (QAPI) Committee meetings and participate in Triple Check Committee meetings.
• Control release of information within State, Federal, and HIPAA regulations, including subpoenas in collaboration with the Director of Clinical Compliance; manage proposal and legal correspondence; maintain confidentiality.
• Provide nursing stations with proper charts and documentation forms; maintain daily census listings and admission/discharge/transfer registers.
• Prepare requests for medical information as directed by the Director of Nursing or Administrator.
• Other duties and responsibilities as assigned at any time with or without notice.

Arbor Lake Nursing and Rehabilitation provides equal employment opportunities to all employees and applicants and prohibits discrimination and harassment of any type based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Salary: $16.00–$27.69 per hour.

Location:

San Antonio, TX. Apply now.