Medical Records assistant- Full time

PACS

11d•Hybrid

About The Position

The primary purpose of this job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines, as well as in accordance with the facility’s established privacy policies and procedures. This role involves administrative functions such as organizing, planning, and directing the medical records department, maintaining minutes of meetings, and fostering good working relationships with inter-departmental personnel. The assistant will also be responsible for recording incidents/accidents, retrieving and filing resident records, assisting the MDS Coordinator, ensuring incomplete records are corrected, and developing procedures for record completion and security. Additionally, the role includes abstracting information for authorized entities, maintaining registries, transcribing reports, batching computer data, answering telephone inquiries, and managing the sign-out/sign-in process for records. A key aspect of the role is adhering to strict privacy and security protocols regarding resident information and facility systems, reporting any suspected violations or unauthorized access. The position assumes administrative authority and responsibility for assigned duties. The role also involves performing secretarial duties for facility committees, collecting and compiling records for review, and preparing reports. Personnel functions include reporting suspected fraud and ensuring workstation security. Staff development involves attending mandatory in-service training and approved workshops. Safety and sanitation require reporting unsafe conditions and equipment malfunctions. Equipment and supply functions include ensuring replenishment and maintaining clean work areas. Budget and planning involve reporting suspected fraud related to billings and cost reports. Other duties as assigned.

Requirements

Must possess, as a minimum, a high school diploma or GED.
Must be able to type a minimum of 45 words per minute.
Must be able to use dictation equipment.
Must be knowledgeable of medical terminology.
Be knowledgeable in computers, data retrieval, input and output functions, etc.
Must be able to read, write, speak, and understand the English language.
Ability to read technical procedures.
Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.
Must possess the ability to make independent decisions when circumstances warrant such action.
Must possess the ability to deal tactfully with personnel, residents, visitors and the general public.
Must possess the ability to work harmoniously with other personnel.
Must possess 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 practices.
Be able to follow written and oral instructions.
Must not pose a direct threat to the health or safety of other individuals in the workplace.
Must be able to move intermittently throughout the workday.
Must be able to speak and write the English language in an understandable manner.
Must be able to cope with the mental and emotional stress of the position.
Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately.
Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel.
Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.
Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.
May be necessary to assist in the evacuation of residents during emergency situations.

Nice To Haves

A working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.
On-the-job training provided in medical record and health information system procedures.

Responsibilities

Maintain resident medical records and health information systems.
Receive and follow work schedule/instructions from supervisor.
Assist in organizing, planning and directing the medical records department.
Maintain minutes of meetings and file as necessary.
Develop and maintain a good working rapport with inter-department personnel.
Assist in recording all incidents/accidents and file accordingly.
Retrieve resident records (manually/electronically) and deliver as necessary.
File information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
Collect, assemble, check and file resident charts as required.
Assist MDS Coordinator in scheduling assessments.
Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.
Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized.
Maintain a record of authorized information released from charts/records.
Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
Index medical records as directed.
Maintain various registries as directed including register for admission and discharge of residents.
Transcribe and type reports for physicians as necessary.
Collect charts, assemble them in proper order, and inspect them for completion.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas as necessary.
Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
Answer telephone inquiries concerning medical records functions.
Prepare written correspondence as necessary.
Retrieve medical records when requested by authorized personnel.
Assure that medical records taken from the department are signed out and signed in upon return.
File active and inactive records in accordance with established policies.
Index medical records as directed.
Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations.
Agree not to disclose resident’s protected health information and promptly report suspected or known violations.
Report any known or suspected unauthorized attempt to access facility’s information system.
Assume the administrative authority, responsibility, and accountability of performing the assigned duties.
Perform secretarial duties for committees of the facility as directed.
Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.
Report known or suspected incidents of fraud to the Administrator.
Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates.
Attend and participate in mandatory facility in-service training programs.
Attend and participate in workshops, seminars, etc., as approved.
Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.
Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
Ensure supplies have been replenished in work areas as necessary.
Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.
Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Perform other duties as assigned.