Medical Records Assistant

Ensign Services•Santa Rosa, CA

7d•Onsite

About The Position

This position adheres to and assures compliance with the Code of Conduct, facility policies and procedures, and all applicable rules, regulations, and standards as promulgated by Federal, State, and accrediting agencies or regulating bodies. This includes, but is not limited to, the Department of Health, Centers of Medicare and Medicaid Services, and other applicable regulatory agencies. The role assures that all staff complete required compliance training and processes. It involves planning, developing, organizing, implementing, evaluating, and directing the medical records section in accordance with established policies and procedures. This includes department policies and procedures, job descriptions, etc. The position establishes procedures for the collection, coding, indexing, and filing/retrieving of medical records. It also assists the medical records director as required, reviews discharge and death records, as well as records on the nursing units, and reviews department policies and procedures at least annually, participating in making recommended changes. The role involves collecting, assembling, checking, and filing resident charts and personnel records as necessary, and ensuring that incomplete records/charts are returned to nursing service for correction. It develops procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing, and ensures established policies and procedures for the medical records section are followed by all personnel. The position establishes procedures to ensure that charts/records are not taken from the section except as authorized and periodically checks such records to assure this policy is being followed. It abstracts information from records as authorized/required for insurance companies, Medicare, etc., and ensures that registries are properly maintained for admission and discharge of residents. The role prepares medical records for court trials as required, and collects and assembles/compiles records for committee review, as requested, preparing reports for staff/other committees as directed, and attending such meetings as may be necessary or appropriate. The position develops and maintains a good working rapport with inter-department personnel, as well as other departments within the facility to assure that medical records can be properly maintained and problem areas can be identified and corrected. It maintains confidentiality by securely collecting and emptying departmental Shred bins on a regular schedule.

Requirements

Must be a graduate of an approved course for medical record technicians.
Must be able to write, read, speak, and comprehend the English language.
Must possess the ability to follow instructions and to accept constructive criticism.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
Must maintain the care and use of supplies, tools, equipment, etc., and maintain the appearance of maintenance work areas.
Must be willing to work harmoniously with other personnel as well as be willing to handle residents based on whatever maturity level they are currently functioning.
Must have the ability to minimize waste of supplies, misuse of equipment, etc.
Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing dietary practices.
Must be able to follow written and oral instructions.
Must be able to relate information concerning a resident's condition.
Must not pose a direct threat to the health or safety of other individuals in the workplace.
Must be able to move continuously throughout the Work Day.
Must be able to cope with the mental emotional and stress of the position.
Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
Must function independently, have flexibility, personal integrity, and the ability to work effectively.
Must meet the general health requirements set forth by the policies of this facility which may include medical and physical examination.
Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.
Must be able to lift up to 50 pounds. Requires infrequent lifting of more weight up to 50 pounds. Occasional pushing and pulling of carts.
May be necessary to assist in the evacuation of residents during emergency situations.

Nice To Haves

High school diploma is preferred.

Responsibilities

Adheres to and assures compliance with Code of Conduct, facility policies and procedures and all applicable rules, regulations and standards.
Assures that all staff complete required compliance training and processes.
Plan, develop, organize, implement, evaluate, and direct the medical records section in accordance with established policies and procedures.
Establish procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records.
Assist the medical records director as required.
Review discharge and death records, as well as records on the nursing units.
Review department policies and procedures, at least annually, and participate in making recommended changes.
Collect, assemble, check, and file resident charts and personnel records as may be necessary.
Ensure that incomplete records/charts are returned to nursing service for correction.
Develop procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing.
Ensure established policies and procedures for the medical records section are followed by all personnel.
Establish procedures to ensure that charts/records are not taken from the section except as authorized.
Abstract information from records as authorized/required for insurance companies, Medicare, etc.
Ensure that registries are properly maintained for admission and discharge of residents.
Prepare medical records for court trials as required.
Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.
Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility.
Maintains confidentiality by securely collecting and emptying departmental Shred bins on a regular schedule.