Medical Records Assistant

The Manor at Blue Water Bay•Niceville, FL

10h•Onsite

About The Position

The position maintains the medical records of the center in accordance with policies and procedures established for the medical record keeping practices.

Requirements

Ability to establish procedures and to suggest changes for smoother operation.
Be able to type and understand the Medical Record Systems, including filing.
Understand and utilize medical terminology, ICD-10-CM, coding principles, concurrent and Discharge Analysis Procedures, medical legal aspects and possess management skills for a nursing home.
Possess personal attributes to include professionalism, neatness, accuracy, articulates pleasantly and cooperative with all staff.
High school graduate or equivalent.
Minimum of 3 – 5 years of management or supervision in the field of medical records, preferably in nursing home setting.
Ability to read, write, hear and communicate adequately to complete job duties and responsibilities.
Ability to move throughout center without assistance.
Must be able to see adequately enough to read hand written medical records.

Nice To Haves

Credentialed individuals may assist as preceptors to local students of an RHIT/RHIA program.

Responsibilities

Determine upon admission of patients whether additional transfer data is needed and obtain missing information.
Make sure that patient’s has an patient armband, in addition to the other required information.
Check medical records quantitatively on admission and periodically (once per month minimum) to assure completeness, accuracy and internal consistency.
Communicate with and assist the medical staff and allied health personnel in updating the records.
Interact with other departments, physicians, administrator and regional support staff.
Maintain flow of reports to the medical records.
Upon discharge, check records quantitatively to assure completeness and accuracy within thirty (30) days of the discharge or in accordance with state requirements.
Ensure that diagnoses have been listed according to ICD-10-CM and that abbreviated diagnoses are not recorded on the Admission-Summary sheet.
Collect, collate and maintain statistical data as needed.
Provide information to Utilization Review Committee, Quality Assurance Committee, medical audits and others as needed or instructed by the administrator.
Maintain the numerical and unit numbering filing system for record identification.
Maintain sign-out and follow-up controls of records.
Maintain and control the release of information to authorized personnel.
Type and/or transcribe reports or correspondence according to the needs of the Medical Records department.
Attend meetings as required by the administrator.
Be able to orient new employees to the procedure of the Medical Records department.
Participate in development of and responsible for compliance with the budget of the Medical Records department.
Other duties as may be assigned from time to time