MEDICAL RECORDS ASSISTANT
Company: Country Hills Post Acute
Location: El Cajon
Posted on: October 27, 2024
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Job Description:
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. Maintain minutes of meetings. File as
necessary. 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. Assist in recording all incidents/accidents. File in
accordance with established policies and procedures. Retrieve
resident records (manually/electronically). Deliver as necessary.
Files 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. Ensure incomplete records/charts are returned to
appropriate departments or personnel for correction. Assist in
developing procedures to ensure resident records are properly
completed, assembled, coded, signed, indexed, etc., before filing.
Establish a procedure to ensure resident charts/records do not
leave the medical records room except as authorized in our policies
and procedures. 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. Maintain various registries as directed including
register for admission and discharge of residents. Transcribe and
type reports for physicians as necessary. 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.) Assure that medical records taken from the
department are signed out and signed in upon return to the
department. File active and inactive records in accordance with
established policies. Index medical records as directed. Agree not
to disclose assigned user ID code and password for accessing
resident/facility information and promptly report suspected or
known violations of such disclosure to the Administrator.--- 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. Assume the
administrative authority, responsibility, and accountability of
performing the assigned duties of this position. Committee
Functions Perform secretarial duties for committees of the facility
as directed. Collect and assemble/compile records for committee
review, as requested, and prepare reports for staff/other
committees as directed. 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 guidelines. Staff
Development Attend and participate in mandatory facility in service
training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse
Prevention, etc.). Attend and participate in workshops, seminars,
etc., as approved. Safety and Sanitation Report all
unsafe/hazardous conditions, defective equipment, etc., to your
supervisor immediately. Equipment and Supply Functions Report
equipment malfunctions or breakdowns to your supervisor as soon as
possible. Ensure supplies have been replenished in work areas as
necessary. Assure that work/assignment areas are clean and records,
files, etc., are properly stored before leaving such areas on
breaks, end of workday, etc. Budget and Planning Functions Report
suspected or known incidence of fraud relative to false billings,
cost reports, kickbacks, etc. Other duties as assigned Supervisory
Requirements ou are delegated the administrative authority,
responsibility, and accountability necessary for carrying out your
assigned duties. Qualification Education and/or Experience Must
possess, as a minimum, a high school diploma or GED. Must be able
to type a minimum of 45 words per minute and use dictation
equipment. A working knowledge of medical terminology, anatomy and
physiology, legal aspects of health information, coding, indexing,
etc., preferred but not required. On the job training provided in
medical record and health information system procedures. Must be
knowledgeable of medical terminology. Be knowledgeable in
computers, data retrieval, input and output functions, etc.
Language Skills Must be able to read, write, speak, and understand
the English language. Ability to read technical procedures.
Mathematical Skills Ability to apply concepts such as fractions,
percentages, ratios and proportions to practical situations.
Reasoning Ability Must possess the ability to make independent
decisions when circumstances warrant such action. Must possess the
ability to deal tactfully with personnel, residents, visitors and
the general public. Must possess the ability to work harmoniously
with other personnel. Must possess the ability to minimize waste of
supplies, misuse of equipment, etc. Must possess the ability to
seek out new methods and principles and be willing to incorporate
them into existing practices. Be able to follow written and oral
instructions. Must not pose a direct threat to the health or safety
of other individuals in the workplace. Physical Demands 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 so that the
requirements of this position can be fully met. 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 and be able to push, pull, move, and/or
carry such weight a minimum distance of 50 feet. May be necessary
to assist in the evacuation of residents during emergency
situations. Work Environment The work environment characteristics
described here are representative of those an employee encounters
while performing the essential functions of this job. Reasonable
accommodations may be made to enable individuals with disabilities
to perform the essential functions. Works in office areas as well
as throughout the facility. Moves intermittently during working
hours. Is subject to frequent interruptions. Works beyond normal
working hours, weekends and holidays and on other shifts/positions
as necessary. Is subject to call back during emergency conditions
(e.g., severe weather, evacuation, post disaster, etc.). Attends
and participates in continuing educational programs. Is subject to
injury from falls, burns from equipment, odors, etc., throughout
the workday, as well as to reactions from dust, disinfectants,
tobacco smoke, and other air contaminants. Is subject to exposure
to infectious waste, diseases, conditions, etc., including TB and
the AIDS and Hepatitis B viruses. Communicates with nursing
personnel, and other department personnel. Is subject to hostile
and emotionally upset residents, family members, personnel,
visitors, etc. Is involved with residents, family members,
personnel, visitors, government agencies and personnel, etc., under
all conditions and circumstances. May be subject to the handling of
and exposure to hazardous chemicals. Additional Information Note:
Nothing in this job specification restricts management's right to
assign or reassign duties and responsibilities to this job at any
time. Critical features of this job are described under various
headings above. They may be subject to change at any time due to
reasonable accommodation or other reasons. The above statements are
strictly intended to describe the general nature and level of the
work being performed. They are not intended to be construed as a
complete list of all responsibilities, duties, and skills required
of employees in this position.
Keywords: Country Hills Post Acute, Oceanside , MEDICAL RECORDS ASSISTANT, Healthcare , El Cajon, California
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