Medical Records Assistant

Rockport Healthcare Services; Fresno (CA); On-site; USD 42,000 - 56,000; Full time

Job summary

Rockport Healthcare Services in Fresno, CA seeks a Health Records Clerk to assist in developing and maintaining an appropriate health record service for the center. You will handle health record systems, administrative tasks, and ensure compliance with Federal, State, and community requirements, while coordinating documentation with physicians and staff.

Strong English communication, medical terminology knowledge, and basic computer skills are required; experience in skilled nursing or health

Qualifications

• High School diploma is 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, Medicare Log (if applicable), Audit System, Discharge Control Log, Chart Removal Log, Resident Care Plan Log, Telephone Audit Log.
• Performs Audits and Admissions/Discharge procedures.
• Coordinates Physician Documentation and Telephone Orders.
• Produces History and Physicals, Monthly Physicians Orders, Physicians’ Progress Notes, Certifications and Recertifications, and Discharge Summaries.
• Thins charts and maintains overflow files as required, maintains minutes of meetings, inputs and prints computerized medical records forms, prepares statistical reports, destroys old health records, assembles discharge records and maintains unit filing system.

Skills

Administrative skills

Organizational skills

Medical terminology

Health records experience

Nursing home experience

Basic computer skills

English communication

Education

High school diploma

Job description

POSITION 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.