Medical Records Assistant

Medical Records Assistant

The Medical Records Assistant plays an integral role in the success of our team, our community and creating a place our residents are proud to call home. The primary purpose of this position is to maintain resident health information systems in accordance with current federal and state guidelines and established policies and procedures.

Essential Job Functions

• Organizes, plans, and manages the medical records department in accordance with established policies and procedures.
• Ensures resident health information is protected and not disclosed unless by permission or with established policies and procedures.
• Retrieves resident records (manually/electronically). Provides as necessary per facility policies.
• Files information such as nursing notes, assessments, progress notes, lab reports, x-ray results, either manually or electronically into resident charts.
• Collects, assembles, checks, and files resident data.
• Ensures incomplete records/charts are returned to appropriate department or personnel for corrections.
• Ensure resident records are properly completed, assembled, coded, etc., before filing.
• Extracts information from records for insurance companies, Medicare, Medicaid, VA, etc., in accordance with established policies and procedures and privacy rules.
• Picks up and delivers medical records to designated areas, as necessary.
• Answers telephone calls to inquiries about medical records. Prepares written correspondence, as necessary.
• Files active and inactive records as per established policies.
• Maintains logs of specific items per established policies and procedures.
• Maintains requests for medical records forms and completes, as necessary.
• Reports noncompliance with policies, procedures, regulations, or breaches of confidentiality to appropriate personnel.
• Reports any retaliation or discrimination to HR or compliance officer.
• Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to supervisor and/or administrator. Cooperate with all investigations.
• Reports any occupational exposures to blood, body fluids, infectious materials, and/or hazardous chemicals in accordance with facility policy.
• Reports work-related injuries and illnesses immediately to supervisor.
• Follows established infection control policies and procedures.
• As a condition of employment, completes all assigned training and skills competency.
• Assist with any training of other staff members.
• Perform other job-related duties as assigned.

Knowledge and Critical Skills

• Be able to make independent decisions and follow instructions.
• Deal tactfully with personnel, prospects, residents, family members, visitors, government agencies/personnel, and the public.
• Capable of working with ill, disabled, elderly, and emotionally upset people within the facility.
• Communicate effectively in a manner that is sufficient for effective communication with supervisors, team members, prospects, residents, and families.
• Knowledge/proficiency of Microsoft Office Suite.

Education and Experience

• Must meet all applicable state and federal requirements for this position.
• High school diploma or equivalent.
• Minimum of 2 years Long Term Care experience preferred.
• Working knowledge of medical terminology, anatomy and physiology, coding, and other aspects of health information preferred, but not required.

Supervisory Responsibility

This position does not have any direct reports or supervisory requirements.

Working Conditions and Physical Demands

Tasks assigned to this position may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals.

Physical Requirements - The Physical activities of this position involve:

• Must be able to lift fifty pounds at times.
• Alternating between standing and sitting

Cognitive Requirements - The Cognitive activities with or without prosthetics of this position are:

• Execute tasks independently.
• Ability to express yourself clearly and effectively.
• General computer literacy

Environmental Requirements - An individual in this position may be exposed to:

• Ambient room temperatures and lighting

Other Requirements -

• n/a

Platinum Service®

Platinum Service® is characterized by a high level of responsiveness delivered in a competent, timely and caring way. Employees commit to providing courteous, responsive, and quality service to our residents by following the principles of our Platinum Service® program.

Conclusion

All employees are expected to follow all policies and procedures. These policies and procedures can be found in the employee handbook, department policy, and procedure manuals and with your supervisor. This job description is intended to convey information essential to understanding the scope of the position and it is not intended to be an exhaustive list of skills, efforts, duties, responsibilities or working conditions associated with the position. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities at any time.

Acknowledgement

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

By signing below, I acknowledge I can perform the essential functions of this job with or without reasonable accommodation. If I require reasonable accommodation, I will inform the recruiter/hiring manager, my manager, or Human Resources and agree to participate in the interactive process to discuss accommodations.

West Hills Health & Rehabilitation, a 113-bed skilled nursing community, has served the Portland community since 1970. Here, team members serve a range of lifestyles and care levels, including skilled nursing rehabilitation, long-term care, and respite care. We take pride in delivering Platinum Service®, our commitment to put residents and their families at the heart of everything we do. Join our team and come see why our team members consistently place West Hills Health & Rehabilitation above other communities as a great place to work. Enjoy the total rewards of competitive pay plus benefits centered on you while performing meaningful work.