Medical Records Specialist

Reports To: Administrator 

Department: Administration  

FLSA Status: Non-Exempt 

Position Type: Full-Time 

Position Summary 

The Medical Records Specialist is responsible for maintaining, organizing, and protecting all resident health information in compliance with state, federal, and facility regulations. This position plays a key role in the admission and discharge process, managed care documentation, and the coordination of information necessary for billing, audits, and reimbursement. The Specialist also provides administrative and clerical support to the Business Office Manager and Administrator to ensure smooth operational workflow and documentation accuracy across all departments. 

Essential Duties and Responsibilities 

Medical Records Management 

• Establish and maintain accurate, up-to-date resident medical records, including admissions, readmissions, transfers, and discharges 

• Verify that each resident record contains all required documentation, physician signatures, progress notes, and care plans as required by regulatory standards 

• Maintain both electronic and paper filing systems, ensuring documents are labeled, indexed, and retrievable 

• Perform ongoing audits of medical records for completeness, accuracy, and compliance with HIPAA, CMS, and state guidelines 

• Track and follow up on physician orders, history and physicals, therapy notes, and other key clinical documentation 

• Respond promptly to authorized requests for health records (insurance companies, surveyors, auditors, physicians, or family members) in accordance with facility policy and privacy laws. 

• Prepare files and participate in state, federal, and corporate audits or surveys; ensure all requested materials are accessible and compliant 

• Maintain retention and destruction of schedules in accordance with facility policy and legal requirements 

Admissions, Managed Care, and Census Tracking 

• Coordinate admission sign-ins for new residents, ensuring all admission packets, consents, and forms are signed, dated, and filed correctly 

• Work with nursing, therapy, and the business office to verify payer source, authorization requirements, and managed care coverage prior to or upon admission 

• Submit and track managed care authorizations, updates, and recertifications, ensuring clinical documentation supports the level of care being billed 

• Maintain detailed logs of census, payer types, authorizations, and discharge dates, and provide regular updates to the Business Office Manager and Administrator 

• Notify the appropriate departments of insurance coverage changes, terminations, or authorization of expirations in a timely manner 

• Communicate proactively with managed care representatives and case managers to minimize denials or delays in payment 

Business Office and Administrative Support 

• Assist the Business Office Manager by providing updated census data, payer status, and documentation necessary for billing and claims submission 

• Review and verify medical documentation for billing accuracy to prevent claim rejections and ensure alignment with reimbursement requirements 

• Organize and maintain files and reports used by the Administrator and Business Office for financial, compliance, and census tracking purposes 

• Assist with preparing and submitting billing packets, daily census reports, and managed care updates 

• Provide clerical support including data entry, scanning, copying, filing, and distribution of interdepartmental communications 

• Support the Administrator by maintaining an organized, confidential, and efficient administrative record system, including resident records, correspondence, and regulatory documentation 

Regulatory Compliance and Quality Assurance 

• Ensure that all health records meet state, federal, and facility standards for completeness and confidentiality 

• Maintain an understanding of CMS, AHCA, and HIPAA regulations and assist with compliance training as needed 

• Participate in Quality Assurance and Performance Improvement (QAPI) activities by providing reports or data from resident records 

• Prepare reports and summaries as requested by the Administrator for survey readiness, compliance reviews, or internal audits 

• Report any privacy breaches, discrepancies, or non-compliance issues immediately to the Administrator or Compliance Officer 

Knowledge, Skills, and Abilities 

• Thorough knowledge of medical terminology, healthcare documentation, and health information standards 

• Familiarity with electronic medical record (EMR) systems used in long-term care (e.g., PointClickCare, MatrixCare, or similar). 

• Understanding billing, insurance, and managed care processes within the healthcare setting. 

• Exceptional organizational skills with strong attention to detail and accuracy. 

• Ability to handle confidential and sensitive information with discretion. 

• Effective communication and teamwork skills; able to work collaboratively with multiple departments. 

• Ability to prioritize workload and meet deadlines in a fast-paced environment. 

Education and Experience Requirements 

• High school diploma or GED required; associate's degree in health information management, Medical Office Administration, or related field preferred 

• Minimum of 2 years of experience in medical records, health information, or billing support within a long-term care, skilled nursing, or healthcare facility 

• Knowledge of HIPAA, CMS, and state record-keeping regulations required 

• Proficiency with Microsoft Office Suite (Word, Excel, Outlook) and EMR software 

Physical and Working Conditions 

• Primarily sedentary work performed in an office environment with frequent interaction with clinical and administrative staff 

• Occasional lifting of files and boxes up to 25 pounds 

• Must adhere to all facility policies, dress code, and confidentiality standards 

Equal Employment Opportunity (EEO) Statement 

Manatee Springs is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. Employment decisions are made without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other protected characteristic under applicable federal, state, or local law. We also provide reasonable accommodations for qualified individuals with disabilities and for sincerely held religious beliefs in accordance with applicable laws.