Medical Records Assistant

1 week ago

Poway, United States Poway Healthcare Center Full time

Poway Healthcare Center is seeking a Full-Time Medical Records Assistant to join our team.

**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.

**Education**
- Must possess, as a 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.

Pay: $20.00 - $27.00 per hour

Expected hours: 40 per week

**Benefits**:

- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance

Schedule:

- 8 hour shift
- Day shift
- Monday to Friday

**Education**:

- High school or equivalent (preferred)

**Experience**:

- Medical Records: 1 year (preferred)

Ability to Commute:

- Poway, CA 92064 (preferred)

Ability to Relocate:

- Poway, CA 92064: Relocate before starting work (required)

Work Location: In person

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