Medical Records Assistant

Role Overview

The Medical Records Assistant is responsible for maintaining resident medical records and managing health information systems in line with federal and state regulations, along with the facility's privacy policies.

Key Responsibilities

• Follow supervisor's instructions and adhere to policy guidelines regarding work schedules and procedures.
• Support the organization, planning, and management of the medical records department.
• Assist the Medical Records/Health Information Consultant as needed and maintain meeting minutes for filing.
• Collaborate with interdepartmental teams to ensure proper maintenance of medical records.
• Record incidents and accidents following prescribed procedures.
• Retrieve and deliver resident records manually or electronically as required.
• File various documentation such as nurses’ notes, assessments, progress notes, lab and x-ray reports, and correspondence in resident charts.
• Collect, assemble, review, and file resident charts ensuring completeness.
• Support MDS Coordinator with scheduling assessments per facility and OBRA guidelines.
• Ensure incomplete records are returned for correction and develop procedures to ensure proper record completion and indexing.
• Manage authorization and tracking of records leaving and returning to the medical records room.
• Abstract information from records for insurance and government entities respecting privacy rules.
• Maintain medical record indices and registries, including admission and discharge registers.
• Transcribe and type physician reports as required.
• Assist with data batching and retrieval of resident demographic information via computer systems.
• Handle telephone inquiries related to medical records and prepare correspondence.
• Ensure secure handling of user credentials and protected health information, reporting any violations promptly.
• Provide secretarial support for facility committees and prepare related reports.
• Report any suspected fraud and ensure computer workstations are secured when unattended.
• Participate in mandatory in-service training and approved educational programs (e.g., OSHA, TB, HIPAA).
• Report unsafe conditions and equipment issues to supervisors promptly.
• Maintain cleanliness and proper organization of work areas and replenish supplies as needed.
• Perform additional duties as assigned, retaining administrative authority and accountability for assigned tasks.

Qualifications

• Minimum of high school diploma or GED required.
• Typing proficiency of at least 45 words per minute and familiarity with dictation equipment.
• Basic knowledge of medical terminology, anatomy, physiology, health information legal aspects, coding, and indexing preferred but not mandatory; on-the-job training provided.
• Computer skills including data entry and retrieval.
• Strong English language skills for reading, writing, speaking, and understanding technical documents.
• Basic math skills to apply concepts such as fractions, percentages, and ratios.
• Ability to make independent decisions, work cooperatively, and maintain professionalism with diverse stakeholders.
• Physical ability to move intermittently throughout the day, lift up to 25 pounds, and assist in emergencies if needed.

Work Environment

• Work occurs in office and facility areas with frequent interruptions and possible extended hours, including weekends and holidays.
• May require call-back during emergencies like severe weather or evacuation.
• Exposure to hazards such as infectious diseases, chemicals, odors, and emotionally charged situations with residents and visitors.

Additional Information

Assignments and responsibilities may be updated or reassigned as needed. The description is not exhaustive of all job duties.

The employer offers equal opportunity employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.