Medical Records Specialist

Arvin Post Acute; Santa Rosa (CA); On-site; USD 29,000 - 32,000; Full time

Job summary

PACS is hiring for a Medical Records Clerk to maintain resident medical records and health information systems in compliance with federal/state guidelines and privacy policies. You will organize, file, and retrieve records, assist in coding and indexing, and support the MDS process within a facility environment.

The role requires attention to detail, 45 wpm typing, and knowledge of medical terminology, with on-the-job training provided. Strong computer skills and confidentiality are essential.

Qualifications

• Must possess, at minimum, a high school diploma or GED.
• Must be able to type a minimum of 45 words per minute and use dictation equipment.
• A working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.
• On-the-job training provided in medical record and health information system procedures.
• Must be knowledgeable of medical terminology.
• Be knowledgeable in computers, data retrieval, input and output functions, etc.

Responsibilities

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
• Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures.
• Assist the Medical Records/Health Information Consultant as required.
• Maintain minutes of meetings. File as necessary.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Retrieve resident records (manually/electronically). Deliver as necessary.
• Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
• Collect, assemble, check and file resident charts as required.
• Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.
• Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.
• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
• Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized in our policies and procedures.
• Maintain a record of authorized information released from charts/records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.
• Index medical records as directed by the medical records/health information consultant.
• Maintain various registries as directed including register for admission and discharge of residents.
• Transcribe and type reports for physicians as necessary.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas as necessary.
• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
• Answer telephone inquiries concerning medical records functions.
• Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.).
• Assure that medical records taken from the department are signed out and signed in upon return to the department.
• File active and inactive records in accordance with established policies.
• Index medical records as directed.
• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
• Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
• Report any known or suspected unauthorized attempt to access facility’s information system.
• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.

Skills

Typing speed

Medical records terminology

Education

High school diploma or GED

Tools

Computers

Job description

PACS is hiring for a Medical Records Clerk to maintain resident medical records and health information systems in compliance with federal/state guidelines and privacy policies. You will organize, file, and retrieve records, assist in coding and indexing, and support the MDS process within a facility environment.

The role requires attention to detail, 45 wpm typing, and knowledge of medical terminology, with on-the-job training provided. Strong computer skills and confidentiality are essential.