Medical Records Assistant

PACS•Los Angeles, CA

1d•Hybrid

About The Position

The primary purpose of your 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 our facility’s established privacy policies and procedures. This role involves administrative functions such as organizing, planning, and directing the medical records department, maintaining good rapport with inter-department personnel, assisting in recording incidents/accidents, retrieving and filing resident records, and ensuring incomplete records are corrected. The position also requires abstracting information for authorized entities, indexing medical records, maintaining registries, transcribing reports, and managing computer data entry. Adherence to privacy policies, including user ID and password security, and reporting any suspected violations are critical. The role assumes administrative authority and responsibility for assigned duties. Additionally, the position involves performing secretarial duties for facility committees, collecting and compiling records for review, and preparing reports. Personnel functions include reporting suspected fraud and ensuring computer workstations are logged off or password protected. 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 functions involve reporting suspected fraud related to billings and cost reports. Other duties as assigned.

Requirements

High school diploma or GED.
Ability to type a minimum of 45 words per minute.
Ability to use dictation equipment.
Knowledgeable of medical terminology.
Knowledgeable in computers, data retrieval, input and output functions.
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.
Ability to make independent decisions when circumstances warrant.
Ability to deal tactfully with personnel, residents, visitors and the general public.
Ability to work harmoniously with other personnel.
Ability to minimize waste of supplies, misuse of equipment.
Ability to seek out new methods and principles and be willing to incorporate them into existing practices.
Ability 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.
Must be able to push, pull, move, and/or carry a minimum of 25 pounds a minimum distance of 50 feet.
May be necessary to assist in the evacuation of residents during emergency situations.
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.

Nice To Haves

Working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.

Responsibilities

Maintain resident medical records and health information systems in accordance with current federal and state guidelines and facility privacy policies.
Organize, plan, and direct the medical records department.
Develop and maintain good working rapport with inter-department personnel.
Record all incidents/accidents and file them.
Retrieve and deliver resident records (manually/electronically).
File information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, and correspondence into resident charts.
Collect, assemble, check, and file resident charts.
Assist MDS Coordinator in scheduling assessments.
Ensure incomplete records/charts are returned for correction.
Develop procedures to ensure resident records are properly completed, assembled, coded, signed, and indexed.
Establish procedures 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 for insurance companies, Medicare, Medicaid, VA, etc., in accordance with current Privacy Rules.
Index medical records as directed.
Maintain various registries, including admission and discharge registers.
Transcribe and type reports for physicians.
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.
Batch resident information into the computer and retrieve resident demographic information.
Answer telephone inquiries concerning medical records functions and prepare written correspondence.
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.
Report known or suspected incidents of fraud.
Ensure departmental computer workstations left unattended are properly logged off or password protected.
Attend and participate in mandatory facility in-service training programs.
Attend and participate in approved workshops, seminars, etc.
Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.
Report equipment malfunctions or breakdowns to your supervisor.
Ensure supplies are replenished in work areas.
Assure that work/assignment areas are clean and records, files, etc., are properly stored.
Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Perform secretarial duties for committees of the facility as directed.
Collect and assemble/compile records for committee review and prepare reports for staff/other committees as directed.