JOB SUMMARY: $15.00-$20.00
The primary purpose of the Medical Records Assistant is providing support to the Medical Records Nurse, the organization, maintenance, and security of medical records in compliance with federal, state, and facility policies. This role ensures timely and accurate filing, retrieval, and documentation of patient health information.
JOBDUTIES & RESPONSIBILITIES:
Administrative Functions
โข Maintainand organize active and discharged medical records in compliance with HIPAAregulations.
โข Fileclinical documentation into patient charts promptly and accurately (paperand/or electronic health records).
โข Ensureall required documentation is present, complete, and signed in accordance withfacility policy and applicable regulations.
โข Preparerecords for audits, state surveys, and regulatory inspections.
โข Track,log, and process medical record requests from external parties (e.g.,hospitals, insurance companies, legal entities) with appropriate authorization.
โข Assistin assembling new resident charts and archiving discharged resident chartsaccording to retention policies.
โข Monitortimely completion of physician signatures and charting requirements.
โข Supportscanning, indexing, and electronic filing of documents into EMR systems.
โข Communicatewith nursing and administrative staff to ensure accurate and updateddocumentation.
โข Assistwith maintaining logbooks, forms inventory, and other clerical tasks related tohealth information management.
โข Ensureconfidentiality of all resident information in compliance with HIPAA andfacility policies.
โข Providegeneral support to the Medical Records Nurse or Health Information Manager asneeded.
โข Receiveand follow work schedule/instructions as outlined in facility policies andprocedures.
โข Developand maintain a good working rapport with inter-department personnel, as well asother departments within the facility, to assure that medical records can beproperly maintained.
โข Assistin organizing and maintaining the facility medical records system in compliancewith corporate, state and federal regulations.
โข Codeand quantify records from admission to discharge.
โข Maintaina documented, organized system which is readily accessible by other authorizedprofessionals.
โข Ensurethat all report are completed within established time frames.
โข Scheduleand maintain a time schedule for all interdisciplinary meetings and keepappropriate personnel informed of the schedule.
โข Pullcharts for physicians' rounds each week and insure that documentation ispresent.
โข MonitorRestrain and Bowl and Bladder Programs to insure documentation is present.
โข Reviewadmission information for accuracy and completeness within 24 hours ofadmission.
โข Ensurethat discharge records and chart are completed within 72 hours of discharge andarrange the file in chronological order in each section so that material can beretrieved in an efficient manner.
โข Filelab and x-ray reports on charts daily.
โข Reviewphysician orders (including telephone orders) and monitor to be sure that lab,x-ray, diagnostic tests, consultations, etc., have been scheduled and followedthrough.
โข Maintainlog/roster to identify when care plan meetings are due.
JOB REQUIREMENTS:
Education
โข LPNlicense Preferred, CNA also considered
โข Somebusiness training preferred
โข MedicalRecords certification preferred
Experience
โข Musthave two (2) years' experience in medical records.
โข Musthave a minimum of six (6) months of experience in a health care environment
โข Musthave a typing speed of 45 wpm or greater
โข Mustbe familiar with Windows computer environment
โข Musthave general office and clerical skills
โข Musthave excellent communication and interpersonal skills
โข Mustpossess a practical knowledge of medical terminology and record keeping
โข Mustbe organized and detailed in work performance
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