Medical Records Assistant

PACS Group•San Diego, CA

16h

About The Position

The Medical Records Assistant supports the organization and operation of the facility’s medical records department. The role maintains resident records, files and retrieves information, assists with assessments and committee work, and helps ensure records are complete, properly handled, and disclosed only as authorized. The position also performs clerical and administrative duties, including maintaining meeting minutes, transcribing reports, preparing correspondence, answering telephone inquiries, and assisting with information systems and departmental supplies. The position requires following facility policies and procedures, protecting resident health information and system credentials, reporting suspected security violations or fraud, and attending required training. Work takes place in office areas and throughout the facility, with frequent interruptions and contact with residents, families, staff, visitors, and government personnel. The role may involve work beyond normal hours, weekends, holidays, other shifts, and emergency call-back.

Requirements

High school diploma or GED.
Ability to type at least 45 words per minute and use dictation equipment.
Knowledge of medical terminology.
Computer skills, including data retrieval and input/output functions.
Ability to read, write, speak, and understand English and read technical procedures.
Ability to apply 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 public, and to work harmoniously with others.
Ability to follow written and oral instructions and incorporate new methods and principles into existing practices.
Ability to minimize waste of supplies and misuse of equipment.
Must not pose a direct threat to the health or safety of others in the workplace.
Ability to move intermittently throughout the workday and cope with the mental and emotional stress of the position.
Adequate sight and hearing, with or without prosthetics, to perform the job requirements.
Must meet facility health requirements, including a medical and physical examination.
Ability to push, pull, move, and/or lift at least 25 pounds to a height of at least 5 feet and carry or move that weight at least 50 feet.
May be required to assist with resident evacuation during emergencies.

Nice To Haves

Working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, and indexing.

Responsibilities

Follow work schedules, supervisor instructions, and established facility policies and procedures.
Assist with organizing, planning, and directing the medical records department and assist the Medical Records/Health Information Consultant as required.
Maintain meeting minutes; perform filing and secretarial duties for facility committees.
Develop and maintain effective working relationships with personnel in other departments.
Assist in recording incidents and accidents.
Retrieve resident records manually or electronically, deliver records as needed, and retrieve them for authorized personnel.
File nurses’ notes, assessments, progress notes, laboratory reports, x-ray results, correspondence, and other information in resident charts.
Collect, assemble, check, inspect, and file resident charts, including returning incomplete records to the appropriate personnel for correction.
Assist the MDS Coordinator with scheduling assessments in accordance with facility and OBRA guidelines.
Assist in developing procedures to ensure records are complete, assembled, coded, signed, indexed, and properly filed.
Ensure resident records do not leave the medical records room except as authorized, and maintain records of information released from charts.
Abstract information from records for insurance companies, Medicare, Medicaid, VA, and other authorized purposes in accordance with privacy rules.
Index medical records and maintain assigned registries, including resident admission and discharge registers.
Transcribe and type physician reports, prepare correspondence, answer telephone inquiries, and compile records and reports for committee review.
Batch resident information into the computer and retrieve demographic information as appropriate or instructed.
Ensure records removed from the department are signed out and signed back in, and file active and inactive records according to established procedures.
Protect assigned user ID codes, passwords, and residents’ protected health information; promptly report suspected or known disclosure violations and unauthorized system access.
Perform assigned administrative duties and report known or suspected fraud, including concerns involving false billings, cost reports, or kickbacks.
Ensure unattended computer workstations are logged off or secured according to facility policy.
Attend mandatory in-service training and approved workshops and seminars.
Report unsafe conditions, defective equipment, and equipment malfunctions; replenish supplies as necessary.
Keep work areas clean and ensure records and files are properly stored.
Perform other duties as assigned.