Medical Record Assistant - Apache Junction

PACS•Apache Junction, AZ

17h

About The Position

The Medical Record Assistant supports the medical records department by organizing, maintaining, retrieving, assembling, indexing, and filing resident records in accordance with facility policies, procedures, and privacy requirements. The role assists the Medical Records/Health Information Consultant and MDS Coordinator, maintains meeting minutes and registries, supports committee work, and handles authorized information requests and correspondence. The assistant is responsible for protecting resident health information and system access credentials, maintaining appropriate records of information released and records checked out, and reporting suspected privacy or security violations, fraud, safety concerns, and equipment problems. The position includes administrative and secretarial duties, computer data entry and retrieval, telephone inquiries, and maintaining clean, orderly work areas and adequately stocked supplies. It requires attendance at mandatory training and approved educational activities, effective communication with residents, families, staff, visitors, and government representatives, and compliance with facility safety and health requirements. The employee may work across office and facility areas, encounter interruptions and potentially hazardous or infectious conditions, and may be called back during emergencies.

Requirements

High school diploma or GED.
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, including reading 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 equipment and to incorporate appropriate new methods and principles into existing practices.
Ability to follow written and oral instructions.
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 function independently and demonstrate personal integrity, flexibility, and effective collaboration.
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.
Must meet the facility’s general health requirements, including medical and physical examination requirements.

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 is provided in medical records and health information system procedures.

Responsibilities

Follow the work schedule and instructions from the supervisor and established 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.
Develop and maintain effective working relationships with personnel in other departments to support proper maintenance of medical records.
Assist in recording incidents and accidents and file documentation according to established procedures.
Retrieve resident records manually or electronically and deliver them as needed; retrieve records for authorized personnel and ensure records taken from the department are signed out and back in.
File nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, and other information in resident charts.
Collect, assemble, inspect, and check resident charts for completion and proper order; ensure incomplete records are returned to the appropriate department or personnel for correction.
Assist the MDS Coordinator with scheduling assessments in accordance with facility and OBRA guidelines.
Assist in developing procedures to ensure resident records are completed, assembled, coded, signed, indexed, and filed appropriately.
Maintain procedures to prevent resident charts or records from leaving the medical records room except as authorized.
Maintain records of authorized information released from charts, including information type, recipient, date, and department.
Abstract information from records as authorized or required for insurance companies, Medicare, Medicaid, the VA, and other applicable entities in accordance with current Privacy Rules.
Index medical records as directed by the medical records/health information consultant.
Maintain assigned registries, including resident admission and discharge registers.
Transcribe and type reports for physicians as necessary and prepare written correspondence as needed.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas.
Batch resident information into the computer and retrieve demographic information as appropriate or instructed.
Answer telephone inquiries concerning medical records functions.
File active and inactive records according to established policies.
Protect assigned user ID codes, passwords, and resident protected health information; promptly report suspected or known disclosure violations to the Administrator.
Report known or suspected unauthorized attempts to access the facility information system.
Perform assigned duties with the administrative authority, responsibility, and accountability delegated for the position.
Perform secretarial duties for facility committees as directed; collect and compile records for committee review and prepare reports as requested.
Report known or suspected fraud to the Administrator, including suspected fraud involving false billings, cost reports, or kickbacks.
Ensure unattended departmental computer workstations are logged off or protected by the facility-approved automatic screen saver.
Attend and participate in mandatory in-service training and approved workshops and seminars.
Immediately report unsafe or hazardous conditions and defective equipment to the supervisor.
Report equipment malfunctions or breakdowns promptly and ensure supplies are replenished as necessary.
Keep work areas clean and ensure records and files are properly stored before breaks and at the end of the workday.
Perform other duties as assigned.
Follow written and oral instructions, make independent decisions when circumstances warrant, deal tactfully with others, work harmoniously with personnel, minimize waste and equipment misuse, and remain open to appropriate new methods and principles.
Meet facility health requirements, including medical and physical examination requirements, and assist with resident evacuation during emergencies if necessary.