Medical Records Assistant

Our expectation is that you will perform your job in a manner consistent with our Core Values CELEBRATION – ACCOUNTABILITY - PASSION FOR LEARNING - LOVE ONE ANOTHER - INTELLIGENT RISK TAKING - CUSTOMER SECOND – OWNERSHIP

POSITION SUMMARY: The primary purpose of your job position is to assure that medical records are maintained in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.

ESSENTIAL DUTIES AND RESPONSIBILITIES: Every effort has been made to identify the essential functions of this position. However, it 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 the position if the work is similar, related, or is an essential function of the position.

* All duties and responsibilities shall be performed as set forth in our established policies and procedures.

* Adheres to and assures compliance with Code of Conduct, facility policies and procedures and all applicable rules, regulations and standards as promulgated by Federal, State, and accrediting agencies or regulating bodies. This includes, but is not limited to, Department of Health, Centers of Medicare and Medicaid Services, and other applicable regulatory agencies.

* Assures that all staff complete required compliance training and processes.

* Plan, develop, organize, implement, evaluate, and direct the medical records section in accordance with established policies and procedures. (Includes department policies and procedures, job descriptions, etc.)

* Establish procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records.

* Assist the medical records director as required.

* Review discharge and death records, as well as records on the nursing units.

* Review department policies and procedures, at least annually, and participate in making recommended changes.

* Collect, assemble, check, and file resident charts and personnel records as may be necessary.

* Ensure that incomplete records/charts are returned to nursing service for correction.

* Develop procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing.

* Ensure established policies and procedures for the medical records section are followed by all personnel.

* Establish procedures to ensure that charts/records are not taken from the section except as authorized. Periodically check such records to assure this policy is being followed.

* Abstract information from records as authorized/required for insurance companies, Medicare, etc.

* Ensure that registries are properly maintained for admission and discharge of residents.

* Prepare medical records for court trials as required.

* Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. Attend such meetings as may be necessary or appropriate.

* 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 and problem areas can be identified and corrected.

Education and Experience

* High school diploma is preferred.

* Must be a graduate of an approved course for medical record technicians.

Other Specific Requirements

* Must be able to write, read, speak, and understand the English language.

* Must possess the ability to follow instructions and to accept constructive criticism.

* Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.

* Must maintain the care and use of supplies, tools, equipment, etc., and maintain the appearance of maintenance work areas.

* Must be willing to work harmoniously with other personnel as well as be willing to handle residents based on whatever maturity level they are currently functioning.

* Must have 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 dietary practices.

* Must be able to follow written and oral instructions.

* Must be able to relate information concerning a resident's condition.

* Must not pose a direct threat to the health or safety of other individuals in the workplace.

WORK ENVIRONMENT

* Works in all areas of the facility.

* Is subject to frequent interruptions and may need to reschedule maintenance activities.

* Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

* Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

* Communicates with maintenance personnel and other department personnel.

* Works beyond normal working hours and on weekends and holidays when necessary, as well as in other positions as needed.

* Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

* Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, 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.

* May be subject to the handling of and exposure to hazardous chemicals.

* May be required to work in cramped spaces and in adverse weather conditions.

PHYSICAL AND SENSORY REQUIREMENTS (with or without the aid of mechanical devices):

* Must be able to move continuously throughout the work day.

* Must be able to cope with the mental emotional and 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 flexibility, personal integrity, and the ability to work effectively.

* Must meet the general health requirements set forth by the policies of this facility which may include a medical and physical examination.

* Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.

* Must be able to lift up to 50 pounds. Requires infrequent lifting of more weight up to 50 pounds. Occasional pushing and pulling of carts.

* May be necessary to assist in the evacuation of residents during emergency situations.

See additional Activity Strength and Frequency Requirements Chart B

ACKNOWLEDGMENT:

This position consistently supports and promotes compliance with the Code of Conduct by maintaining the privacy and confidentiality of information, protecting the assets of the facility, acting with ethics and integrity, reporting non-compliance, and adhering to applicable Federal, State, and local laws and regulations, accreditation and licensure requirements (if applicable), and all policies and procedures.

I understand that signing this job description does not create a contract of employment, guarantee employment for any definite period of time, or in any way affect my employee-at-will status. I understand as an employee-at-will I may terminate my employment, or the company may terminate my employment, at any time, with or without cause and with or without notice.

Job Types: Full-time, Part-time

Pay: $22.00 - $27.00 per hour

Benefits:

• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday
• Weekends as needed

Work Location: In person

Salary : $22 - $27