Medical Records Assistant

Stillwater-Post-Acute; El Cajon (CA); On-site; USD 42,000 - 54,000; Full time

Job summary

Stillwater Post-Acute in El Cajon, CA seeks a Medical Records Assistant to organize and protect patient records, ensuring accuracy and accessibility for authorized staff.

The role emphasizes HIPAA compliance, data privacy, and collaboration with clinicians to verify documentation, with opportunities to work with EHR systems and improve records workflows.

Qualifications

• High school diploma or equivalent required; associate degree or certification preferred.
• Basic knowledge of medical terminology and healthcare documentation standards.
• Familiarity with electronic health record (EHR) systems and standard office software.
• Strong attention to detail and organizational skills.
• Ability to handle sensitive information with confidentiality and professionalism.

Responsibilities

• Organize, review, and maintain patient medical records in electronic and paper formats to ensure accuracy and completeness.
• Verify the accuracy of medical documentation, and collaborate with healthcare providers to resolve discrepancies.
• Ensure compliance with federal, state, and institutional privacy and data security regulations, including HIPAA.
• Respond to requests for medical records from authorized personnel, patients, and external entities in a timely and confidential manner.
• Assist in the implementation and maintenance of EHR systems and train staff on records management procedures.

Skills

Attention to detail

Organizational skills

Confidentiality & professionalism

Knowledge of EHR systems

Education

High school diploma or equivalent

Associate degree or health information management certification

Tools

EHR software (Epic/Cerner/Meditech)

Job description

Stillwater Post-Acute , located in El Cajon, is a premier post-acute care facility with 256 beds, dedicated to delivering exceptional, patient-centered care that promotes recovery and enhances residents' quality of life. We offer a wide range of tailored services, including short-term rehabilitation, long-term care, and comprehensive therapy options such as physical, occupational, and speech therapy.

At Stillwater Post-Acute, we prioritize teamwork and leadership, ensuring that all department heads are accessible and supportive. We offer a variety of educational and hands-on training opportunities to promote your career growth in a collaborative environment that values your contributions. You’ll work alongside dedicated professionals committed to enhancing patient care, with plenty of chances for advancement and a great boss who truly cares about your success.

About the Role:

The Medical Records Assistant plays a critical role in managing and maintaining accurate and confidential patient health information within healthcare facilities. This position ensures that medical records are properly documented, organized, and accessible to authorized personnel, supporting effective patient care and compliance with legal and regulatory standards. The role involves coordinating with healthcare providers to collect, verify, and update patient data, facilitating smooth clinical operations. Additionally, the Medical Records Staff is responsible for safeguarding sensitive information, adhering to privacy laws such as HIPAA, and implementing best practices in records management. Ultimately, this position contributes to the overall efficiency and quality of healthcare delivery by maintaining the integrity and availability of medical records.

Minimum Qualifications:

• High school diploma or equivalent required; associate degree or certification in health information management preferred.
• Basic knowledge of medical terminology and healthcare documentation standards.
• Familiarity with electronic health record (EHR) systems and standard office software.
• Strong attention to detail and organizational skills.
• Ability to handle sensitive information with confidentiality and professionalism.

Preferred Qualifications:

• Certification as a Registered Health Information Technician (RHIT) or Certified Medical Records Technician (CMRT).
• Experience working in a healthcare setting, particularly in medical records or health information management.
• Advanced proficiency with EHR software such as Epic, Cerner, or Meditech.
• Knowledge of coding and billing processes related to medical records.
• Strong communication skills to effectively liaise with clinical staff and external agencies.

Responsibilities:

• Organize, review, and maintain patient medical records in both electronic and paper formats to ensure accuracy and completeness.
• Verify the accuracy of medical documentation, and collaborate with healthcare providers to resolve discrepancies or incomplete information.
• Ensure compliance with federal, state, and institutional regulations regarding patient privacy and data security, including HIPAA guidelines.
• Respond to requests for medical records from authorized personnel, patients, and external entities in a timely and confidential manner.
• Assist in the implementation and maintenance of electronic health record (EHR) systems and support staff training on records management procedures.

Skills:

The required skills enable the Medical Records Staff to accurately manage and organize patient information, ensuring that all documentation is complete and compliant with healthcare regulations. Proficiency with electronic health record systems allows for efficient data entry, retrieval, and updating of patient files, which is essential for supporting clinical decision-making. Attention to detail is critical in identifying and correcting discrepancies in medical records, thereby maintaining data integrity. Confidentiality and professionalism are paramount when handling sensitive patient information, ensuring compliance with privacy laws such as HIPAA. Preferred skills, such as certification and experience with advanced EHR platforms, enhance the ability to streamline records management processes and improve communication with healthcare providers and external entities.

We provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, sex (including pregnancy, childbirth, or related condition), age, national origin or ancestry, citizenship, disability, marital status, sexual orientation, gender identity or expression (including transgender status), genetic predisposition or carrier status, military or veteran status, familial status, status as a victim of domestic violence, or any other status protected by law.