MEDICAL RECORDS ASSISTANT

Almond Vista Healthcare; Modesto (CA); On-site; USD 42,000 - 50,000; Full time

Job summary

Almond Vista Healthcare in Modesto, CA is seeking a detail-oriented Medical Records Assistant to transcribe orders, input data into EMR, and maintain patient charts with accuracy. The role requires strong English reading skills and excellent communication with staff and families.

The candidate should be proficient in Word and Excel, and have high school education. Responsibilities include ensuring chart integrity and supporting state survey readiness while maintaining confidentiality and

Qualifications

• Education: High School graduate or equivalent.
• Must read, analyze, and interpret common scientific/technical information in English.
• Basic arithmetic and numerical ability required.
• Exceptional communication and customer service skills.
• Must be able to key information into computer systems with accuracy.

Responsibilities

• Transcribe physician and nursing orders accurately in a timely manner.
• Enter information into EMR and physician/nursing orders into computer systems.
• Maintain resident medical charts and ensure privacy and confidentiality.
• Communicate changes to nursing staff and other departments as required.
• Assist with chart audits, state inspections prep, and disaster drills as directed.

Skills

Typing (basic)

Typing (advanced)

Proficient in English

Good communication

Medical terminology

Reading & interpreting technical info

Customer service

Computer literacy

Education

High School graduate or equivalent

Tools

Word

Excel

Job description

ESSENTIAL JOB FUNCTIONS:• Transcribe, accurately, physician and nursing orders on appropriate documents in a timely manner• Keys information into computer systems, including EMR• Assure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as required• Record accurate, legible information about resident care and condition in appropriate sections of resident’s records• Follow facility policies and procedures including those related to infection control• Capable to perform new duties as assigned and trained• Maintain resident medical charts, station documents and supplies• Input physician and nursing orders to computer• Establish and maintain effective communication both written and verbal• Able to interact effectively with individuals who are cognitively and/or physically impaired• Organize nursing stations and maintain a tidy work environment• Perform chart audits as assigned• Demonstrate ability to maintain confidentiality of resident and facility information• Prioritize workload and complete projects accurately and in a timely manner• Assist with preparation for state inspections as directed. Attend survey training and interact with state surveyors asdirected by immediate supervisor• Demonstrate interpersonal skills that contribute to a positive work environment• Demonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactions• Provide excellent service to staff, visitors, and residents• Answer telephone professionally and in accordance with facility policy• Demonstrate competence in use of proper body mechanics for both upper and lower body• Monitor physical environment for safety or fire hazards and corrects or reports potential problems immediately toCharge Nurse. Promptly reports housekeeping and maintenance problems to Charge Nurse• Report injury to resident or self to Charge Nurse immediately• Participate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure residentsafety• Knowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond towritten or oral instruction in case of emergency• Adhere to policies and proceduresJOB FUNCTIONS:• Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions• Appreciates the importance of maintaining confidentiality of resident and facility information• Demonstrate honesty and integrity at all times in the care and use of resident and facility property• Must be able to key information into computer systems• Good communication skills both verbal and written• Proficient in English• Able to understand and follow written and verbal directions• Working knowledge of basic computer programs: Word and Excel• Basic and advanced typing• Basic and advanced filing• Working knowledge of medical terminology• Open, flexibility to changing needs of the Medical Records Department• Other duties as assignedQUALIFICATIONS/REQUIREMENTS:Education: High School graduate or equivalentLicense: None RequiredWork Experience: Previous experience in medical records preferredLanguage Skills:• Must be able to read, analyze, and interpret common scientific and technical information, and to be easilyunderstood through verbal communication in the English language.Mathematical Skills:• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, commonfractions, and decimals.• Ability to perform these operations using units of weight measurement, and volume.Communication Skills:• Must have exceptional communication and customer service skills, and be empathetic.• Ability to effectively communicate with patients, families, responsible parties, staff and outside resources andagencies.