Medical Records Assistant

Skyline Healthcare Center-San Jose; San Jose (CA); On-site; USD 28,000 - 29,000; Full time

Job summary

Skyline Healthcare Center-San Jose is seeking a detail-oriented Medical Records Clerk to manage patient records, ensure accuracy, and support audits in a long-term care setting. The role involves chart preparation for admissions, record disposition at discharge, and confidentiality adherence.

Responsibilities include maintaining indexing, auditing schedules, and coordinating forms while complying with state and federal regulations and facility policies.

Qualifications

• High school diploma or equivalent.
• Working knowledge of medical terminology.
• Proficient in the use of a personal computer.

Responsibilities

• Prepares charts for new admissions.
• Closes medical records upon discharge.
• Develops schedule for and conducts audits of the clinical and electronic health records.
• Monitors physician visit schedule.
• Maintains master index system.
• Orders, maintains, and distributes medical records forms.
• Monitors procedures to maintain confidentiality of patient information and guard against loss or destruction of data in accordance with the facility’s policy and procedures.
• Maintains records and completes required forms and documents in accordance with facility policies and state and/or federal regulations.

Skills

Medical terminology

Personal computer

Education

High school diploma or equivalent

Job description

*The following statements are intended to describe the general nature and level of work being performed and are not intended to be a complete list of all responsibilities, duties and skills required.

SUMMARY

Responsible and accountable for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

include the following. Other duties may be assigned.

• Prepares charts for new admissions.
• Closes medical records upon discharge.
• Develops schedule for and conducts audits of the clinical and electronic health records.
• Monitors physician visit schedule.
• Maintains master index system.
• Orders, maintains, and distributes medical records forms.
• Monitors procedures to maintain confidentiality of patient information and guard against loss or destruction of data in accordance with the facility’s policy and procedures.
• Maintains records and completes required forms and documents in accordance with facility policies and state and/or federal regulations.

ENTRY QUALIFICATIONS

• High school diploma or equivalent.
• Working knowledge of medical terminology.
• Proficient in the use of personal computer.

SUPERVISORY RESPONSIBILITIES

N/A

PHYSICAL DEMANDS AND ENVIRONMENT

Working in normal office environment, employee may be required to sit, bend, stoop, use keyboard, see, talk and hear. May occasionally lift objects of 10 to 25 lbs. In compliance with applicable law, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

OTHER REQUIREMENTS

Participates in (or conducts) company-sponsored training to safeguard against improper use and disclosure of resident’s protected health information. Monitors and oversee facility’s efforts to comply with company policies, procedures and state and federal law. By his / her signature below, employee agrees to adhere to and oversee communication of privacy guidelines relative to the confidentiality of residents' protected health information.

JOB DESCRIPTION REVIEW

I understand this job description, its requirements and that I am expected to complete all duties as assigned. I understand the job duties may be altered from time to time.

SALARY RANGE: FROM $20.00 to $21.00 PER HOUR DEPENDING ON EXPERIENCE