Medical Records Assistant

Medical Records Assistant

The Medical Records Assistant is responsible for providing administrative and clerical support to the Medical Records department to ensure resident medical records are accurate, complete, organized, and maintained in compliance with facility policies and applicable state and federal regulations.

This position primarily focuses on scanning, uploading, filing, tracking, and organizing resident documentation within the facility's electronic health record (EHR) system, PointClickCare (PCC). The Medical Records Assistant supports daily documentation audits, identifies missing records, and assists with maintaining survey readiness.

This position does not require an LPN or RN license. The ideal candidate will possess strong organizational skills, attention to detail, computer proficiency, and the ability to maintain confidentiality when handling sensitive resident information.

Essential Duties and Responsibilities

1. Medical Records Management

• Scan, upload, index, and organize resident medical documentation into PointClickCare (PCC).
• Ensure documents are accurately uploaded to the appropriate resident chart and designated section.
• Maintain complete, organized, and accessible electronic medical records.
• Assist with processing admission, transfer, discharge, and other resident-related documentation.
• Review documents for completeness, legibility, and appropriate identification before scanning.
• Maintain an organized workflow to prevent backlogs in medical record processing.

2. Scanning and Documentation

• Scan and upload required resident documents, including but not limited to:
• Preadmission Screening and Resident Review (PASRR) documentation.
• Hospice records and related documentation.
• Dental records and consultation reports.
• Admission packets and signed admission documents.
• Hospital discharge summaries and transfer paperwork.
• Physician orders and other clinical documents as directed.
• Outside provider records and consultation documentation.
• Ensure documents are filed promptly and accurately.
• Identify missing, incomplete, or incorrectly filed documents and notify the appropriate department.
• Assist with reducing outstanding scanning and documentation backlogs.

3. Medical Records Auditing and Compliance

• Assist with daily medical record audits using facility-established checklists and procedures.
• Verify that required documents are present in resident charts.
• Maintain tracking logs for missing documentation and outstanding records.
• Follow up with appropriate departments regarding missing or incomplete paperwork.
• Support preparation for state surveys, regulatory inspections, and internal audits.
• Report documentation discrepancies to the Medical Records Coordinator, Director of Nursing, or designated supervisor.
• Assist with implementing corrective actions related to medical record organization and documentation completeness.

4. Administrative and Departmental Support

• Organize incoming medical records, correspondence, and documentation requests.
• Maintain filing systems, scanning logs, and documentation tracking tools.
• Communicate with nursing, admissions, social services, and other departments to obtain missing records.
• Assist with retrieving medical records for authorized staff and approved requests.
• Support the Medical Records department with additional clerical responsibilities as assigned.
• Prioritize daily scanning, auditing, and documentation tasks according to department needs.

5. Confidentiality and Regulatory Compliance

• Maintain strict confidentiality of resident medical information in accordance with HIPAA and applicable privacy laws.
• Follow facility policies regarding the handling, storage, transmission, and disposal of confidential records.
• Access resident information only as necessary to perform assigned job duties.
• Immediately report potential documentation errors, privacy concerns, or compliance issues to the appropriate supervisor.
• Maintain professional standards when communicating with residents, families, staff, and outside providers.

Minimum Qualifications

Education

• High school diploma or GED required.
• Additional education or certification in medical records, health information management, or healthcare administration preferred but not required.

Experience

• Previous administrative, clerical, data entry, or document management experience preferred.
• Experience in a healthcare, skilled nursing, long-term care, or medical office setting preferred.
• Experience with PointClickCare or another electronic health record system preferred.
• Previous scanning, filing, or medical records experience is beneficial.

Licensure

• No nursing license required.
• No medical certification required.

Required Knowledge, Skills, and Abilities

• Strong attention to detail and accuracy.
• Ability to organize and manage large volumes of documentation.
• Proficiency with computers, electronic filing systems, scanners, and Microsoft Office applications.
• Ability to learn and navigate PointClickCare.
• Strong time management and organizational skills.
• Ability to prioritize assignments and meet established deadlines.
• Ability to identify missing documentation and communicate concerns appropriately.
• Understanding of confidentiality and willingness to follow HIPAA requirements.
• Ability to work independently with minimal supervision.
• Effective verbal and written communication skills.
• Ability to collaborate with nursing, admissions, social services, and administrative departments.

Physical Requirements

• Ability to sit or stand for extended periods while completing administrative tasks.
• Frequent use of computers, scanners, printers, and other office equipment.
• Ability to bend, reach, and retrieve files as necessary.
• Ability to lift and carry office materials weighing up to 20 pounds, with or without reasonable accommodation.

Performance Expectations

• Complete assigned scanning and uploading tasks accurately and within established timelines.
• Maintain organized electronic records with minimal filing errors.
• Assist with completion of daily documentation audits.
• Identify and communicate missing documentation promptly.
• Contribute to reducing outstanding medical record backlogs.
• Maintain resident confidentiality and compliance with facility procedures.
• Support ongoing survey readiness through accurate and timely record management.

Additional Responsibilities

The Medical Records Assistant may perform other related administrative duties as assigned by the Director of Nursing or designated supervisor, consistent with the employee's training, qualifications, and scope of responsibilities.

Equal Employment Opportunity

Cedar Sinai Park is an equal opportunity employer and is committed to providing equal employment opportunities to all qualified applicants and employees in accordance with applicable federal, state, and local laws.