Medical Record Assistant - Apache Junction

PACS Group•Apache Junction, AZ

About The Position

The Medical Record Assistant supports the organization and operation of the facility’s medical records department. The role maintains, retrieves, assembles, indexes, and files resident records; handles authorized disclosures and record requests; supports assessments, committees, and administrative tasks; and follows privacy, security, safety, and facility procedures. The position works with residents’ protected health information and facility information systems, and must promptly report suspected privacy, security, fraud, safety, or equipment issues. Duties may be reassigned, and the description is not an exhaustive list of responsibilities.

Requirements

High school diploma or GED.
Type at least 45 words per minute and use dictation equipment.
Knowledge of medical terminology.
Computer knowledge, including data retrieval and input/output functions.
Ability to read, write, speak, and understand English and read technical procedures.
Ability to apply fractions, percentages, ratios, and proportions to practical situations.
Ability to make independent decisions when circumstances warrant.
Ability to deal tactfully with personnel, residents, visitors, and the general public and work harmoniously with other personnel.
Ability to minimize waste and misuse of supplies and equipment, follow written and oral instructions, 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.
Ability to move intermittently throughout the workday and cope with the mental and emotional stress of the position.
Adequate sight and hearing, with or without prosthetics, to perform the position’s requirements.
Ability to work independently with personal integrity and flexibility, and effectively with other personnel.
Must meet the facility’s general health requirements, including medical and physical examination.
Ability 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

Follow the supervisor’s work schedule and instructions and established policies and procedures.
Assist with organizing, planning, and directing the medical records department and assist the Medical Records/Health Information Consultant as required.
Maintain meeting minutes; perform filing; and develop and maintain effective working relationships with personnel across departments.
Assist with recording incidents and accidents.
Retrieve, deliver, collect, assemble, inspect, and file resident records and charts, including information such as 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.
Return incomplete records to the appropriate departments or personnel for correction and assist in developing procedures for completing, assembling, coding, signing, and indexing records before filing.
Help ensure resident charts leave the medical records room only as authorized, and maintain records of authorized information released from charts.
Abstract authorized information for insurance companies, Medicare, Medicaid, the VA, and other required purposes in accordance with current privacy rules.
Index medical records and maintain designated registries, including resident admission and discharge registers.
Transcribe and type physician reports as necessary; prepare written correspondence; and answer telephone inquiries concerning medical records functions.
Batch resident information into the computer and retrieve resident demographic information as appropriate or instructed.
Retrieve records requested by authorized personnel and ensure records removed from the department are signed out and signed back in upon return.
File active and inactive records in accordance with established policies.
Protect assigned user ID codes, passwords, resident protected health information, and facility information systems; promptly report suspected or known disclosure violations and unauthorized access attempts 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 fraud to the Administrator, including suspected fraud related to false billings, cost reports, or kickbacks.
Ensure unattended departmental workstations are logged off or protected by the facility-approved automatic screen saver.
Attend and participate in mandatory in-service training and approved workshops or seminars.
Report unsafe or hazardous conditions and defective equipment to the supervisor; report equipment malfunctions promptly.
Replenish supplies as necessary and leave work areas clean, with records and files properly stored.
Carry out assigned duties with the administrative authority, responsibility, and accountability delegated for the position.
Perform other duties as assigned.