Medical Records assistant

Overview

Medical Records assistant-Full Time (Healthcare)

• Receive and follow work schedule/instructions from your supervisor and as outlined in established policies and procedures.
• Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures.
• Assist the Medical Records/Health Information Consultant as required and maintain minutes of meetings.
• File as necessary and develop a good working rapport with interdepartmental personnel to ensure proper maintenance of medical records.
• Assist in recording incidents/accidents and file in accordance with established policies and procedures.
• Retrieve resident records (manually/electronically) and deliver as necessary.
• File information such as nurses  notes, resident assessments, progress notes, laboratory reports, x-ray results, and other correspondence into resident charts; collect, assemble and file resident charts as required.
• Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.
• Ensure incomplete records/charts are returned for correction; develop procedures to ensure records are properly completed, assembled, coded, signed and indexed before filing.
• Establish procedures to prevent charts/records from leaving the medical records room without authorization; maintain a record of information released from charts/records including type of information, recipient, date, and department.
• Abstract information from records as required for insurance companies, Medicare, Medicaid, VA, etc., in accordance with current Privacy Rules.
• Index medical records as directed by the medical records/health information consultant and maintain registries (e.g., admission and discharge).
• Transcribe and type reports for physicians as necessary; collect and inspect charts for completion; batch resident information into the computer and retrieve demographic information as instructed.
• Answer telephone inquiries concerning medical records functions and prepare written correspondence as needed.
• Retrieve medical records when requested by authorized personnel (physicians, nurses, government agencies, etc.). Ensure records taken from the department are signed out and signed in upon return; file active and inactive records per policies.
• Agree not to disclose assigned user /password or resident protected health information and promptly report violations to the Administrator.
• Report known or suspected unauthorized attempts to access facility information systems.
• Assume the administrative authority, responsibility, and accountability of performing assigned duties.
• Perform committee secretarial duties; collect/compile records for committee review and prepare reports as directed.
• Report known or suspected incidents of fraud; ensure unattended computer workstations are logged off or screensavers activated per policy.

• Education and/or
  
  Experience:
  
  Must have a minimum high school diploma or GED.
• Typing:
  Ability to type at least 45 words per minute and use dictation equipment.
• Knowledge:
  Working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing (preferred but not required).
• On-the-job training provided in medical records and health information system procedures.
• Computer literacy:
  Knowledge of computers, data retrieval, input and output functions.
• Language:
  Ability to read, write, speak and understand English; ability to read technical procedures.
• Mathematical
  
  Skills:
  
  Ability to apply fractions, percentages, ratios and proportions to practical situations.
• Reasoning Ability:
  Ability to make independent decisions when warranted and to interact tactfully with personnel, residents, visitors, and the public; ability to minimize waste and adopt new methods as appropriate.
• Physical Demands:
  Ability to move intermittently, speak and write in English clearly, cope with mental and emotional stress, have adequate senses, and lift/carry up to 25 pounds and push/pull for distances as required.
• Work Environment:
  Office and facility settings; subject to interruptions; may require work beyond normal hours; exposure to various hazards and infectious materials; ability to handle hostile or upset individuals.
• Other:
  Must meet health requirements and may be required to participate in emergency evacuations.

Note:

Nothing in this job specification restricts management s right to assign or reassign duties and responsibilities to this job at any time. The statements are intended to describe the general nature and level of work performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required at this position.