Medical Records

Mapleview Country Villa • Chardon, OH

20h

About The Position

The Medical Records Clerk maintains accurate, complete, and confidential resident medical records in accordance with facility policy, HIPAA regulations, and state and federal long-term care requirements. The role supports clinical, administrative, and survey functions by keeping records organized, current, and audit-ready.

The clerk assembles, audits, and maintains electronic and paper records; monitors documentation for completeness and accuracy; and follows up with nursing and interdisciplinary staff as needed. The role also supports admissions, discharges, transfers, and readmissions, assists with audits and survey preparation, processes record requests under release-of-information policies, and supports electronic medical record workflows and documentation standards. The position collaborates with nursing, therapy, social services, and administrative staff while safeguarding protected health information.

Requirements

• High school diploma or equivalent.
• Previous experience in medical records, health information management, or healthcare administration; long-term care experience is preferred.
• Working knowledge of HIPAA and confidentiality requirements.
• Strong attention to detail and organizational skills.
• Ability to manage multiple tasks and meet deadlines.

Nice To Haves

• Experience in a long-term care or skilled nursing facility.
• Familiarity with electronic medical record (EMR) systems.
• Certification in Health Information Management (RHIT or RHIA), or coursework in HIM; preferred but not required.
• Experience with CMS survey processes and audits.

Responsibilities

• Maintain resident medical records in compliance with HIPAA, CMS, and facility policies.
• Assemble, audit, and maintain electronic and paper medical records.
• Ensure documentation is completed on time and is properly ordered and accurate.
• 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 according to release-of-information policies.
• Maintain confidentiality and safeguard protected health information (PHI).
• Collaborate with nursing, therapy, social services, and administrative staff.
• Support electronic medical record (EMR) system workflows and documentation standards.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED