Medical Records Assistant Jobs in Rockingham, NC

SUMMARY: 

The Clinical staff (CMA, General Clinic CST, or LPN I) are multi-skilled health professionals who work interdependently with other healthcare professionals to provide quality healthcare to the patient. They are trained to perform both administrative and clinical skills. The goal of the clinical staff is to optimize outcomes and improve the quality of life for patients through efficient, cost-effective care.

POSITION REQUIREMENTS:

People:

Patient Satisfaction/Responding to Patients:

1.  Appropriately schedules time off/Limit unscheduled absences
2.  Respond to telephone inquiries relating to department services. 
3.  Return patient calls promptly.
4.  Notify Patient of test results in a timely manner per clinic/department policy
5.  Provide clean and comfortable environment for patients.
6.  Perform all duties in a timely and efficient manner. 
7.  Schedule follow-ups as needed 

Service: 

Prepare patients for examinations, procedures and give follow up injections (if applicable)

1.  Greet and arrive the patient 
2.  Follow patient verification protocol
3.  Provide high level of customer service
4.  Accurately obtain and record medical histories verify all allergies, medications, and vital signs per clinic and department protocol
5.  Order, collect and prepare laboratory specimens as needed
6.  Explain treatment procedures
7.  Ensure proper consents have been signed prior to the procedure by both the patient and MD
8.  Draw up and/or give injections as ordered by MD
9.  Perform vial testing for follow-up patients per department protocol

Assist the physician during examinations and procedures as needed: 

1.  Provide educational materials and aftercare instructions
2.  Supply proper equipment
3.  Applies universal precautions and maintain a sterile field as appropriate for procedures
4.  Prepare dressings 
5.  Clean and dress wounds by order of physician
6.  Take photographs
7.  Remove staples or sutures
8.  Prepare and administer medications as directed
9.  Order x-rays, cultures
10.  Respond to prescription requests/refills 
11.  Perform other clinical functions as delegated and supervised by the physician
12.  Escort patient to the secretary, patient access service associate, or financial counselor 
13.  Prepare pathology form, cup collection label, log and record per policy
14.  Recognize and respond to emergencies per policy

Perform administrative duties as directed:

1.  Document patient communications and treatments accurately and appropriately
2.  Answer telephones and respond to clinical voice mail messages per policy 
3.  Obtain prior authorization for medications
4.  Manage KPI reports including duplicate medication and medical reconciliation
5.  Maintain task lists
6.  Complete charge tickets, labels, consents, dx codes
7.  Other duties as assigned

Post Operative Follow up

1.  Calls post-operative patients 
2.  Responds to prescription requests/refills.
3.  Provides aftercare instructions.

Quality:

Computers: Electronic Medical Records & Practice Management Tasks:

1. Accurate Documentation of: All patient history, injections and patient education per clinic policy
2. Input charges, notes etc. into Touch works per policy
3. E-Fax and call prescriptions
4. Monitor & complete daily clinical tasks per department protocol

Maintain rooms, equipment and supplies: 

1. Clean rooms and change linens per clinic policy.
2. Empty exam rooms of instruments that need to be cleaned secure nurse’s station cabinets nightly.
3. Dispose of all biohazard material per clinic policy
4. Assist with ordering clinical supplies as needed. Put away stock upon arrival.
5. Perform inventory of products and prepare reports as requested.
6. Maintain inventory and stocking of products 
7. Sterilize and clean equipment and supplies per established protocols
8. Ensure maintenance of equipment is maintained.
9. Review department stock medications 
10. Clean exam room and nurses station counters and chairs per clinic policy

Safety: Ensure Patient & Staff Safety: 

1.  Follow OSHA guidelines
2.  Follow universal precautions when caring for patients; Use PPE as directed
3.  Follow all PSC policies when caring for patients
4.  Provide wheelchairs and assist patients with ambulation as needed.
5.  Ask for assistance when needed for lifting or transfer patients 

Finance:

Proactively Assist in Fiscal Management of Clinic Resources:

1. Assist with maintaining established par levels on regularly used supplies.
2. Avoid the need to over-night items or pay increased shipping fees for “rush orders.” 
3. Notify manager or discuss with peers blocks of time when there are no appointments to 
4.  maximize down time completing tasks that are difficult to due during a busy clinic.

Growth:

Work Collaboratively to Promote Increase in Clinic Patient Volume

1. Assist MD’s, department manager and marketing director with department as needed
2. Look for ways to expand the clinic services and patients. Discuss with department manager as needed. 

 Other duties as assigned 

This document is intended to describe the general nature and level of work performed. It is not intended to serve as an exhaustive list of all duties, skills, and responsibilities required of personnel so classified.

Refer to the department policy and procedure manual for procedure specific personal protective equipment requirements. 

PREFERRED QUALIFICATIONS:

1. Graduation from a accredited Medical Assisting, Surgical Tech or Practical Nursing Program 
2. Current Certification or Licensure with no restrictions
3. Current BLS Certification
4. Knowledge of infection control, sterile technique and basic health and safety precautions applicable for work in a clinic setting
5. Use and apply medical terminology appropriately
6. Thorough knowledge of general clinical principles, methodology and measures for outcomes
7. Administrative skills necessary to effectively manage office practice
8. Requires ability to stand for up to eight hours a day, bend, reach, squat, kneel, move, lift of patients and/or equipment up to 50 lbs.

PERSONAL CHARACTERISTICS:

1. High energy level 
2. Strong interpersonal skills; tactful
3. Ability to relate sensitively to patients needs
4. Excellent telephone skills and etiquette 
5. Maintains confidentiality
6. Uses discretion and sound judgment
7. Ability to establish credibility with physicians, staff, and patients
8. Ability to multi-task; resourceful and well organized; takes initiative
9. Always mindful of quality improvement and cost efficient care
10. Team player
11. Ability to maintain positive attitude
12. Well-groomed
    

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