MDS Assistant

PACS

About The Position

The MDS Assistant supports the medical records department and MDS Coordinator by maintaining resident records, assisting with assessment scheduling, and ensuring records are properly assembled, indexed, filed, retrieved, and protected. The position also provides administrative and secretarial support to facility committees, maintains registries and meeting minutes, and prepares correspondence and reports. The role requires safeguarding confidential resident and facility information, following established policies and procedures, and reporting suspected privacy, security, safety, or fraud concerns. Other duties may be assigned.

Requirements

High school diploma or GED at minimum.
Ability to type at least 45 words per minute and use dictation equipment.
Knowledge of medical terminology.
Knowledge of computers and data retrieval, input, and output functions.
Ability to read, write, speak, and understand English; read technical procedures; and follow written and oral instructions.
Ability to apply fractions, percentages, ratios, and proportions to practical situations.
Ability to make independent decisions when circumstances warrant, deal tactfully with others, work harmoniously with personnel, minimize waste and equipment misuse, and incorporate new methods and principles into existing practices.
Must not pose a direct threat to the health or safety of others in the workplace.
Must be able to move intermittently throughout the workday and cope with the mental and emotional stress of the position.
Must have adequate sight and hearing, or prosthetics that enable those senses to function adequately for the job.
Must function independently and demonstrate personal integrity, flexibility, and the ability to work effectively with others.
Must meet facility general health requirements, including a medical and physical examination.
Must be able to push, pull, move, and/or lift at least 25 pounds to a height of at least 5 feet and carry or move that weight at least 50 feet.
May need to assist with resident evacuation during emergencies.

Nice To Haves

Working knowledge of anatomy and physiology, legal aspects of health information, coding, and indexing; preferred but not required.
On-the-job training is provided in medical record and health information system procedures.

Responsibilities

Assist in organizing, planning, and directing the medical records department according to established policies and procedures, and assist the Medical Records/Health Information Consultant as required.
Maintain meeting minutes; file records and information; and maintain a good working relationship with personnel across departments.
Assist in recording incidents and accidents; retrieve, deliver, collect, assemble, inspect, and file resident records and charts.
File resident documentation, including nurses’ notes, assessments, progress notes, laboratory reports, x-ray results, and correspondence.
Assist the MDS Coordinator with scheduling assessments in accordance with facility and OBRA guidelines.
Ensure incomplete records are returned to the appropriate department or personnel for correction, and assist in developing procedures for completing, assembling, coding, signing, and indexing records.
Help ensure resident records leave the medical records room only as authorized; maintain records of authorized disclosures and abstract information for insurers and government programs in accordance with current privacy rules.
Index medical records and maintain registries, including resident admission and discharge registers, as directed.
Transcribe and type physician reports as necessary; prepare correspondence; and answer telephone inquiries about medical records functions.
Batch resident information into the computer and retrieve demographic information as appropriate or instructed.
Retrieve records for authorized personnel and ensure records removed from the department are signed out and signed in when returned.
File active and inactive records according to established policies and procedures.
Protect user IDs, passwords, and residents’ protected health information; report suspected disclosure violations or unauthorized system access to the Administrator.
Perform secretarial duties for facility committees; collect and compile records for committee review and prepare reports as directed.
Report known or suspected incidents of fraud to the Administrator, including suspected fraud relating to false billings, cost reports, or kickbacks.
Ensure unattended departmental computer workstations are logged off or protected by an automatic screen saver in accordance with facility policy.
Attend mandatory in-service training and approved workshops or seminars.
Report unsafe conditions, defective equipment, equipment malfunctions, and breakdowns to a supervisor; replenish supplies as needed; and keep work areas clean and records properly stored.
Assume the administrative authority, responsibility, and accountability necessary to perform assigned duties; perform other duties as assigned.