Medical Records Assistant (Skilled Nursing Facility)

Job Description

Job Description

REQUIREMENTS:

 

1. High School diploma or equivalent.

2. Knowledge of medical terminology, typing skills, and familiarity with office practices and procedures are essential.

3. Ability to work systematically, demonstrate initiative, and complete tasks independently without constant supervision.

4. Capability to follow established protocols and suggest improvements for smoother operations when necessary.

5. Must maintain good physical and mental health.

 

REPORTING:

 

The Medical Records Assistant reports directly to the Medical Records Director.

 

JOB DUTIES:

 

1. Process daily mail and filing, including copying Telephone Orders and managing mail-outs.

2. Handle incoming calls related to Medical Records.

3. Conduct assigned room checks and provide assistance as needed.

4. Perform Telephone Order Audits.

5. Execute Medication Audits.

6. Carry out Weekly Summary Audits.

7. Conduct Treatment Audits.

8. Perform Certified Nursing Assistant Audits, including any relevant logs.

9. Oversee Admission Audits.

10. Manage Physician Visits and follow-up calls, ensuring documentation in the patient’s record.

11. Update General Logs monthly and as required.

12. Process Discharge Charts.

13. Prepare admission charts as necessary.

14. Print Reports and input Physician Orders as needed.

15. Maintain the nurses' stations with necessary forms and make copies as required.

16. Assist nursing staff, MDs, and other personnel with follow-ups as necessary.

17. Copy Patient Records as requested.

18. Conduct Qualitative Audits as needed.

19. Provide coverage for the Receptionist when required.

20. Complete additional duties as assigned by the Medical Records Director and/or Administrator.