Medical Records Assistant - Novato

Rockport Healthcare Services; Novato (CA); On-site; USD 42,000 - 64,000; Full time

Job summary

Rockport Healthcare Services in Novato, CA seeks a Health Records Assistant to develop and maintain resident health record systems in compliance with Federal and State requirements. This role supports administrative duties and documentation processes within a skilled nursing setting.

The incumbent will maintain health record logs, coordinate physician documentation, conduct routine audits, and prepare statistical reports.

Qualifications

• High School diploma is required.
• Knowledge of medical terminology is necessary.
• Experience with health record systems 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 and related logs (Admissions/Discharge Register, Master Patient Index, Disease Index, Medicare Log, Audit System).
• Performs audits and maintains various logs incl. Discharge, Chart Removal, Care Plan, Telephone Audit, and Physicians' Orders.
• Coordinates physician documentation and discharge summaries; handles history and physicals and monthly physician orders.
• Destroys old health records as required and assembles/distributes discharge records.
• Maintains unit filing system and prints computerized medical records forms.
• Presents a professional image to consumers and adheres to company standards for resolving concerns.

Skills

Administrative skills

Medical terminology

Health records experience

Basic computer skills

English proficiency

Written communication

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.