Medical Records Assistant

Rockport Healthcare Services; Chico (CA); On-site; USD 25,000 - 39,000; Full time

Job summary

Rockport Healthcare Services seeks a detail-oriented Health Records Clerk to support the center's health record system and ensure compliance with federal, state, and community requirements. You will assist in developing and maintaining accurate health records for residents in a skilled nursing setting.

Responsibilities include initiating and maintaining health record logs, coordinating physician documentation, preparing statistical reports, and performing routine audits.

Qualifications

• High School diploma required.
• Strong written and verbal English for business.
• Administrative and organizational ability.
• Knowledge of medical terminology.
• Previous experience in a skilled nursing home health care setting.
• Prior health record experience preferred.
• Basic computer experience preferred.

Responsibilities

• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.
• Initiates Resident Health Record.
• Initiates and maintains logs and indices as required: Admission/Discharge Register, Master Patient Index, Disease Index.
• Performs Audits and Routine Quality Assurance Audits.
• Coordinates Physician Documentation and History and Physicals.
• Discharge Summaries and Discharges; maintains unit filing system.

Skills

English proficiency

Administrative ability

Medical terminology

Health records experience

Basic computer skills

Nursing home setting experience

Education

High School diploma

Job description

OSITION DESCRIPTION:

Assists in developing and maintaining an appropriate health record service and system for the center.

QUALIFICATIONS

• High School diploma.
• Strong written and verbal skills in English necessary for business.
• Administrative and organizational ability.
• Knowledge of medical terminology.
• Previous experience in a skilled nursing home health care setting.
• Prior health record experience preferred.
• Basic computer experience preferred.

GENERAL DUTIES AND RESPONSIBILITIES:

ADMINISTRATIVE

• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.

TECHNICAL

• Initiates Resident Health Record.
• Initiates and maintains logs and indices as required:
• Admission/Discharge Register
• Master Patient Index
• Disease Index
• Medicare Log (if applicable)
• Audit System
• Discharge Control Log
• Chart Removal Log
• Resident Care Plan Log
• Telephone Audit Log
• Performs Audits
• Admissions
• Discharge
• Routine Quality Assurance Audits
• Special as required
• Coordinates Physician Documentation
• Telephone Orders
• History and Physicals
• Monthly Physicians Orders
• Physicians’ Progress Notes
• Certifications and Recertifications
• Discharge Summaries
• Thins charts and maintains overflow files as required.
• Records and maintains minutes of meetings as assigned.
• Inputs and prints computerized medical records forms.
• Prepares statistical reports as required.
• Destroys old health records as required.
• Assembles, analyzes and completes discharge records.
• Maintains unit filing system.

CONSUMER SERVICE

• Presents professional image to consumers through dress, behavior and speech.
• Adheres to Company standards for resolving consumer concerns.
• Ensures that all consumer/resident rights are protected.