Medical Records Clerk

Medical Records Assistant – Job Duties and Responsibilities Essential Functions Interpersonal, Teamwork & Misc. Communicates unresolved work-related issues productively & effectively solves problems Handles confidential information appropriately and is HIPAA compliant Friendly and courteous to residents, co-workers etc, and takes ownership in solving problems (taking initiative where appropriate) Works well in a team, owning personally assigned work and assisting wherever needed to get the job done Follows established policies and guidelines Reliable and predictable attendance Other Duties as assigned 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. 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.) Page 2 of 3 Revised June 2020 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 screensaver 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 safely 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. Resident Rights Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information. Knock before entering a resident’s room. Assure that residents’ rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are followed. Physical Capabilities Must be able to move intermittently throughout the workday. Page 3 of 3 Frequent bending and reaching. Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met. Must meet the general health requirements set forth by the policies of this facility which includes an annual TB screening and physical examination. Must be able to sit for extended periods of time. Must be able to lift and carry up to 25 pounds. Must be able to cope with the mental and emotional stress of the position. Environment Conditions Inside work, normal temperatures, some noise, occasional fumes/odors, chemical exposure, and potential exposure to bloodborne pathogens. This job cannot be performed without exposure to the stresses associated with an intimate, 24-hour skilled care environment that delivers care and services primarily to disabled and cognitively impaired residents in an aging population. Examples of these stresses include, but are not limited to: emergency health or safety response, weekend and holiday duty, unusual or impaired behavior by residents, family reactions to having a loved one in a nursing home, death and dying, oversight of state surveyors, ombudsmen and federal officials, presence of consultants and attorneys, and variable involvement of medical staff. HIPAA is a law that must be followed by all healthcare personnel at every level. This position is a Mandated Reporter regarding the suspicion of elder abuse and may have access to Protected Health Information (PHI). ACKNOWLEDGEMENT: Every effort has been made to identify the essential functions of this position. However, this in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from this position. I hereby accept the position and agree to perform this position in a safe manner and in accordance with the facility’s established procedures. I understand that as a result of my employment, I may be exposed to blood, body fluids, burn, infectious diseases, air contaminants (including tobacco smoke), hazardous chemicals, and to the Hepatitis B virus, and that I will be responsible for following company policies and procedures when in contact with any of the situations described above. I understand that my employment is at will. My employment is for no definite or determinable period and may be terminated at any time with or without prior notice at the option of either myself or the company. No promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the facility Administrator. _______________________________________________ Employee Signature ____________________________________ Date Revised June 2020

Job Type: Full-time

Pay: From $18.00 per hour

Expected hours: 32 – 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Ability to Commute:

• Fair Oaks, CA 95628 (Required)

Ability to Relocate:

• Fair Oaks, CA 95628: Relocate before starting work (Required)

Work Location: In person

Salary : $18