Medical Records Serenity Spring Senior Living at Green Bay Green Bay, WI Job Details Part-time 9 hours ago Qualifications High school diploma or GED Full Job Description Part-Time Medical Records Clerk Serenity Spring Senior Living at Green Bay The Part-Time Medical Records Clerk is responsible for maintaining, organizing, and safeguarding resident medical records in accordance with federal, state, and facility regulations. This role ensures accurate documentation, confidentiality compliance, and timely processing of medical information to support quality resident care in a long-term care environment. Essential Duties and Responsibilities Maintain resident medical records in both electronic and paper formats. Assemble, file, scan, and audit medical records for completeness and accuracy. Ensure compliance with HIPAA and facility confidentiality policies. Process physician orders, diagnostic reports, and other documentation. Assist with chart thinning, record purging, and archiving per retention guidelines. Prepare records for admissions, discharges, and transfers. Respond to requests for medical records in accordance with legal and regulatory requirements. Support state surveys and audits by organizing and retrieving documentation. Monitor documentation for required signatures and completion. Maintain tracking logs for record requests and releases. Communicate with nursing staff and department heads regarding documentation needs. Perform additional clerical duties as assigned.

Qualifications Education:

High school diploma or GED required. Coursework in Health Information Management or related field preferred.

Experience:

Prior experience in medical records, healthcare administration, or long-term care preferred. Experience working with electronic medical record (EMR) systems is a plus. Knowledge, Skills, and Abilities Strong organizational and time management skills. High attention to detail and accuracy. Knowledge of HIPAA regulations and medical record confidentiality standards. Ability to work independently and maintain productivity in a part-time capacity. Proficient in Microsoft Office and EMR systems. Strong written and verbal communication skills. Ability to handle sensitive information with discretion. Work Environment Healthcare setting within a long-term care facility. May require occasional interaction with residents, families, and regulatory surveyors. Must adhere to infection control policies and procedures.