Medical Records Assistant

Oakwood Healthcare Center; Chico (CA); On-site; USD 42,000 - 62,000; Full time

Job summary

Oakwood Healthcare Center is seeking an Administrative Health Records Clerk to maintain patient records, manage admissions and discharges, and support quality assurance in a skilled nursing setting. This role emphasizes accuracy, confidentiality and timely documentation.

The candidate should have a high school diploma, excellent English communication, and basic computer skills to support physician documentation, data entry and reports. On-site duties and professional presentation are required.

Qualifications

• High School diploma required.
• Strong written and verbal English.
• Knowledge of medical terminology.
• Administrative and organizational abilities.
• Experience in skilled nursing home health care setting preferred.
• Basic computer experience required.

Responsibilities

• Maintains Health Record System according to regulations.
• Participates in meetings and inservices.
• Initiates Resident Health Records and related logs.
• Manages admissions, discharges and related records.
• Maintains and audits charts, indices and logs.
• Prepares statistical reports as required.
• Destroys old health records as required.
• Coordinates physician documentation and orders.
• Inputs and prints computerized medical records forms.
• Provides professional consumer service and protects resident rights.

Skills

English fluency

Admin skills

Organizational skills

Medical terminology

Computer literacy

Healthcare experience

Education

High School diploma

Job description

OSITION DESCRIPTION:

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.