Medical Records Assistant

Skilled Nursing Professionals•Santa Rosa, CA

5d•Onsite

About The Position

This position is responsible for adhering to the Code of Conduct, facility policies, and all applicable regulations. The Medical Records Assistant plans, develops, organizes, implements, and evaluates the medical records section. This includes establishing procedures for collection, coding, indexing, and filing/retrieving medical records, as well as assisting the medical records director. The role involves reviewing various resident records, ensuring compliance with policies, and abstracting information for authorized entities. Additionally, the position requires maintaining registries, preparing records for legal proceedings, compiling records for committee review, and fostering inter-departmental collaboration. Confidentiality is maintained through secure handling of departmental shred bins.

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.
Plans, develops, organizes, implements, evaluates, and directs the medical records section in accordance with established policies and procedures.
Establishes procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records.
Assists the medical records director as required.
Reviews discharge and death records, as well as records on the nursing units.
Reviews department policies and procedures, at least annually, and participates in making recommended changes.
Collects, assembles, checks, and files resident charts and personnel records as may be necessary.
Ensures that incomplete records/charts are returned to nursing service for correction.
Develops procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing.
Ensures established policies and procedures for the medical records section are followed by all personnel.
Establishes procedures to ensure that charts/records are not taken from the section except as authorized.
Periodically checks such records to assure this policy is being followed.
Abstracts information from records as authorized/ for insurance companies, Medicare, etc.
Ensures that registries are properly maintained for admission and discharge of residents.
Prepares medical records for court trials.
Collects and assembles/compiles records for committee review, as requested, and prepares reports for staff/other committees as directed.
Attends such meetings as may be necessary or appropriate.
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.
Maintains confidentiality by securely collecting and emptying departmental Shred bins on a regular schedule.