Medical Records Assistant

PACS•San Diego, CA

2d•$21 - $23

About The Position

The Medical Records Assistant supports the organization and operation of the facility’s medical records department. The role maintains, retrieves, organizes, indexes, and files resident records; assists with assessment scheduling and record completion; handles authorized information requests and disclosure logs; and provides administrative and committee support. The assistant follows facility policies and procedures and protects resident health information and information-system access. On-the-job training in medical record and health information system procedures is provided.

Requirements

High school diploma or GED.
Type a minimum of 45 words per minute and use dictation equipment.
Knowledge of medical terminology.
Knowledge of computers, data retrieval, and input and 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 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.
Must meet the facility’s general health requirements, including a medical and physical examination.
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, with or without prosthetics, to perform the position’s requirements.
Must be able to push, pull, move, 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 is preferred but not required.

Responsibilities

Follow work schedules, supervisor instructions, and established policies and procedures.
Assist in organizing, planning, and directing medical records department activities and support the Medical Records/Health Information Consultant as required.
Maintain meeting minutes, perform filing, and develop cooperative working relationships with facility departments.
Record incidents and accidents and file information according to established procedures.
Retrieve resident records manually or electronically, deliver them as needed, and file resident documentation in charts.
Collect, assemble, check, inspect, and file resident charts; return incomplete records 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 records are complete, assembled, coded, signed, indexed, and properly filed.
Ensure resident charts leave the medical records room only as authorized, and maintain records of authorized information released.
Abstract information from records for authorized purposes, including insurance, Medicare, Medicaid, and VA requests, in accordance with current Privacy Rules.
Index medical records and maintain registries, including admission and discharge registers, as directed.
Transcribe and type reports for physicians, prepare written 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 back in.
File active and inactive records according to established policies.
Protect assigned user IDs, passwords, and residents’ protected health information; report suspected or known disclosure violations and unauthorized system-access attempts.
Perform secretarial duties for facility committees, assemble records for committee review, and prepare requested reports.
Report known or suspected fraud, including fraud related to false billings, cost reports, or kickbacks.
Ensure unattended computer workstations are logged off or protected by the facility-approved automatic screen saver.
Attend required in-service training and approved workshops or seminars.
Report unsafe conditions, hazards, defective equipment, and equipment malfunctions to a supervisor.
Replenish supplies as needed and keep work areas clean and records properly stored.
Perform other duties as assigned.