Medical Records Assistant

The Goodman Group, LLC•Portland, OR

About The Position

The Medical Records Assistant maintains resident health information systems in accordance with applicable federal and state guidelines and established facility policies and procedures. The role organizes and manages the medical records department, protects confidential resident information, processes and files records, and supports the accurate completion and maintenance of resident charts. The position also helps ensure compliance with privacy, infection-control, and workplace safety requirements, and provides responsive service to residents, families, staff, and others requesting records. This position has no direct reports or supervisory requirements. Employees are expected to complete assigned training and competency requirements, assist with training other staff as needed, follow facility policies and procedures, and perform other job-related duties as assigned.

Requirements

Meet all applicable state and federal requirements for the position.
High school diploma or equivalent.
Ability to make independent decisions and follow instructions.
Ability to deal tactfully with personnel, prospective residents, residents, family members, visitors, government agencies and personnel, and the public.
Ability to work with ill, disabled, elderly, and emotionally upset people.
Effective communication skills with supervisors, team members, prospective residents, residents, and families.
Knowledge or proficiency with Microsoft Office Suite.
Ability to lift fifty pounds at times.
Ability to alternate between standing and sitting.
Ability to execute tasks independently and express oneself clearly and effectively.
General computer literacy.

Nice To Haves

A minimum of two years of long-term care experience is preferred.
Working knowledge of medical terminology, anatomy and physiology, coding, and other aspects of health information is preferred but not required.

Responsibilities

Organize, plan, and manage the medical records department in accordance with established policies and procedures.
Protect resident health information and prevent unauthorized disclosure.
Retrieve resident records manually or electronically and provide them as required by facility policy.
File nursing notes, assessments, progress notes, laboratory reports, X-ray results, and other information in resident charts.
Collect, assemble, check, and file resident data.
Return incomplete records or charts to the appropriate department or personnel for correction.
Ensure resident records are completed, assembled, and coded before filing.
Extract information from records for insurance companies, Medicare, Medicaid, the VA, and other parties in accordance with policy and privacy rules.
Pick up and deliver medical records to designated areas as needed.
Answer telephone inquiries about medical records and prepare written correspondence as necessary.
File active and inactive records according to established policies.
Maintain logs and medical-record request forms, and complete forms as necessary.
Report policy or regulatory noncompliance, confidentiality breaches, retaliation, discrimination, suspected resident abuse or mistreatment, occupational exposures, and work-related injuries or illnesses to the appropriate personnel.
Cooperate with investigations and follow established infection-control policies and procedures.
Complete assigned training and skills competency requirements and assist with training other staff members.
Provide courteous, responsive, and quality service to residents and families in accordance with the Platinum Service® program.
Perform other job-related duties as assigned.