Medical Records Assistant

Healthcare-Center-of-Fresno; Fresno (CA); On-site; USD 38,000 - 58,000; Full time

Job summary

Healthcare-Center-of-Fresno is seeking an on-site Health Records Clerk in Fresno, CA to assist in developing and maintaining an accurate health record system for the center. The role requires strong English communication, administrative skills, and knowledge of medical terminology.

Responsibilities include maintaining records, managing logs and indices, coordinating physician documentation, and performing routine audits to support quality care and regulatory compliance.

Qualifications

• High School diploma required.
• Excellent written and verbal English for business communication.
• Strong administrative and organizational abilities.
• Knowledge of medical terminology helpful and preferred.

Responsibilities

• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.
• Initiates Resident Health Record and related logs and indices.
• Manages Admissions and Discharges, Master Patient Index, Disease Index and Medicare Log as applicable.
• Performs routine audits, chart maintenance, and statistics reporting.
• Coordinates physician documentation, including telephone orders and progress notes.
• Ensures patient rights are protected and presents a professional image to consumers.

Skills

Communication skills

Administrative ability

Medical terminology knowledge

Basic computer skills

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.