Medical Record Assistant

PACS

1d•$18 - $20•Onsite

About The Position

The Medical Record Assistant maintains resident medical records and health information systems in accordance with current federal and state guidelines and the facility’s privacy policies and procedures. The position supports the medical records department with record retrieval, filing, indexing, assembly, data entry, correspondence, committee support, and related administrative work. The schedule is 10:00 a.m. to 4:00 p.m., and the pay range is $18–$20 per hour. The role requires protecting resident information and facility information systems, maintaining records in accordance with established procedures, and working cooperatively with facility departments, residents, families, visitors, and authorized outside personnel. On-the-job training in medical record and health information system procedures is provided. The work takes place in office areas and throughout the facility, with possible exposure to interruptions, infectious waste and diseases, hazardous chemicals, and other conditions described in the posting.

Requirements

High school diploma or GED.
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, including reading technical procedures.
Ability to apply fractions, percentages, ratios, and proportions to practical situations.
Ability to make independent decisions when circumstances warrant, follow written and oral instructions, and deal tactfully and harmoniously with personnel, residents, visitors, and the public.
Ability to minimize waste and misuse of equipment, and willingness to seek out and incorporate new methods and principles.
Must not pose a direct threat to the health or safety of others in the workplace.
Must be able to move intermittently during the workday and cope with the mental and emotional stress of the position.
Must have adequate sight and hearing, with or without prosthetics, to perform the position’s requirements.
Must meet the facility’s 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 medical terminology, anatomy and physiology, legal aspects of health information, coding, and indexing; preferred but not required.
On-the-job training in medical record and health information system procedures is provided.

Responsibilities

Follow the work schedule, supervisor instructions, and facility 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 and file them as necessary.
Maintain effective working relationships with personnel and departments to support proper maintenance of medical records.
Assist with recording and filing incident and accident information.
Retrieve, deliver, collect, assemble, inspect, and file resident records and charts, including active and inactive records.
File clinical and administrative information in resident charts, 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 departments or personnel for correction; assist with procedures for completing, assembling, coding, signing, and indexing records before filing.
Maintain procedures to prevent records from leaving the medical records room except as authorized, and track records taken from and returned to the department.
Maintain records of authorized disclosures and abstract information for insurers and government programs as authorized and in accordance with current privacy rules.
Index medical records as directed and maintain assigned registries, including resident admission and discharge registers.
Transcribe and type reports for physicians as necessary; answer telephone inquiries and prepare correspondence as needed.
Batch resident information into the computer and retrieve demographic information as appropriate or instructed.
Perform secretarial duties for facility committees; assemble records for committee review and prepare reports as directed.
Report known or suspected fraud, unsafe conditions, defective equipment, and equipment malfunctions to the appropriate supervisor or Administrator as applicable.
Ensure unattended departmental workstations are logged off or protected by an automatic screen saver in accordance with facility policy.
Attend and participate in mandatory in-service training and approved workshops and seminars.
Replenish supplies as necessary and keep work areas clean, with records and files properly stored.
Carry out assigned duties and other duties as assigned while protecting user credentials, resident protected health information, and facility information systems.