Medical Records Assistant

Wage DOE: $18-21/hour

General Purpose

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.

Essential Duties

Administrative Functions

• Receive and follow work schedule/instructions from your supervisor and as outlined in our 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.

• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.

• Retrieve resident records (manually/electronically).

Deliver as necessary.

• Files/scans 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 in accordance with current facility and OBRA guidelines.

• Maintain a record of authorized information released from charts/records, i.e., type information, name of recipient, date, department, etc.

• Abstract information from records as authorized/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.

• 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 (i.e., physicians, nurses, government agencies and personnel, etc.)

• File active and inactive records in accordance with established policies.

• Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

• Report any known or suspected unauthorized attempt to access facility's information system.

• Input physician orders on admit and code diagnosis using ICD-10 coding guidelines

Personnel Functions

• 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 within established facility policy guideline...