Medical Records Assistant

PACS•Bartow, FL

2d•$15 - $23

About The Position

The Medical Records 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 role supports the organization and operation of the medical records department, helps ensure records are complete and properly maintained, and protects residents’ confidential health information. The position also provides administrative and secretarial support to facility committees, participates in required staff training, reports safety and equipment concerns, and helps maintain clean, orderly work areas and adequate supplies. The employee may work in office areas and throughout the facility, and may be required to work beyond normal hours, weekends, holidays, or other shifts as needed, including during emergencies. The stated pay range is $15–$23. The employer is an equal opportunity employer.

Requirements

High school diploma or GED.
Ability to type at least 45 words per minute.
Ability to 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 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 and work harmoniously with personnel, residents, visitors, and the general public.
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 position’s mental and emotional stress.
Must have adequate sight and hearing, with prosthetics if needed, to meet job requirements.
Must function independently and demonstrate personal integrity and flexibility.
Must meet the facility’s general health requirements, including a 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 medical terminology, anatomy and physiology, legal aspects of health information, coding, and indexing; these are preferred but not required.
On-the-job training in medical record and health information system procedures is provided.

Responsibilities

Follow the supervisor’s work schedule and instructions and established facility policies and procedures.
Assist in 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 needed.
Maintain a good working rapport with facility personnel and other departments to support proper medical records maintenance.
Assist with recording and filing incidents and accidents.
Retrieve, deliver, collect, assemble, inspect, and file resident medical records and charts, including active and inactive records.
File nurses’ notes, assessments, progress notes, laboratory reports, x-ray results, correspondence, and other information in resident charts.
Assist the MDS Coordinator with scheduling assessments in accordance with facility and OBRA guidelines.
Ensure incomplete records are returned to the appropriate department or personnel for correction.
Assist in developing procedures for completing, assembling, coding, signing, and indexing records before filing, and ensure records leave the medical records room only as authorized.
Maintain records of authorized information released from charts, including the information type, recipient, date, and department.
Abstract information from records for insurers and government programs, including Medicare, Medicaid, and VA, as authorized and in accordance with privacy rules.
Index medical records and maintain registries, including admission and discharge registers, as directed.
Transcribe and type reports for physicians as needed.
Batch resident information into the computer and retrieve demographic information as appropriate or instructed.
Answer telephone inquiries about medical records functions and prepare written correspondence as necessary.
Retrieve records for authorized personnel and ensure records taken from the department are signed out and signed in upon return.
Protect assigned user IDs, passwords, and residents’ protected health information; report suspected or known disclosure violations and unauthorized attempts to access the facility information system to the Administrator.
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 concerns related to false billings, cost reports, and kickbacks.
Ensure unattended departmental computer 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.
Immediately report unsafe or hazardous conditions and defective equipment to the supervisor; report equipment malfunctions or breakdowns as soon as possible.
Replenish supplies as necessary and leave work areas clean with records and files properly stored.
Perform other duties as assigned.