Full Time Medical Records Assistant

Job description

Our goal is to wonderfully enrich thousands of lives, one person at a time. We are dedicated to providing person-centered health care services and are passionate about serving our residents and their families in a nurturing, transitional environment between hospital and home.

POSITION:
The Medical Records Assistant is to perform accurate and timely transcription of physician, nursing and other provider orders; computer order entry; maintaining resident medical charts and communicating pertinent information to staff members

REPORTING:
This position is responsible to the Medical Records Director.

FLSA STATUS: Non-Exempt

QUALIFICATIONS/REQUIREMENTS:

Education: High School graduate or equivalent
License: None Required

Work Experience: Previous experience in Medical Records preferred

Language Skills:

• Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language.

Mathematical Skills:

• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to perform these operations using units of weight measurement, and volume.

Communication Skills:

• Must have exceptional communication and customer service skills, and be empathetic.
• Ability to effectively communicate with patients, families, responsible parties, staff and outside resources and agencies.

ESSENTIAL JOB FUNCTIONS:

• Transcribe, accurately, physician and nursing orders on appropriate documents in a timely manner
• Keys information into computer systems, including EMR
• Assure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as required
• Record accurate, legible information about resident care and condition in appropriate sections of resident’s records
• Follow facility policies and procedures including those related to infection control
• Capable to perform new duties as assigned and trained
• Maintain resident medical charts, station documents and supplies
• Input physician and nursing orders to computer
• Establish and maintain effective communication both written and verbal
• Able to interact effectively with individuals who are cognitively and/or physically impaired 2
• Organize nursing stations and maintain a tidy work environment
• Perform chart audits as assigned
• Demonstrate ability to maintain confidentiality of resident and facility information
• Prioritize workload and complete projects accurately and in a timely manner
• Assist with preparation for state inspections as directed. Attend survey training and interact with state surveyors as directed by immediate supervisor
• Demonstrate interpersonal skills that contribute to a positive work environment
• Demonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactions
• Provide excellent service to staff, visitors, and residents
• Answer telephone professionally and in accordance with facility policy
• Demonstrate competence in use of proper body mechanics for both upper and lower body
• Monitor physical environment for safety or fire hazards and corrects or reports potential problems immediately to
• Charge Nurse. Promptly reports housekeeping and maintenance problems to Charge Nurse
• Report injury to resident or self to Charge Nurse immediately
• Participate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure resident safety
• Knowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond to written or oral instruction in case of emergency
• Adhere to policies and procedures

HIPAA is a law that must be followed by all healthcare personnel at every level. This position is a Mandated Reporter
regarding the suspicion of elder abuse and may have access to Protected Health Information (PHI).

Job Type: Full-time

Pay: $16.00 - $18.00 per hour

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Medical records: 1 year (Required)

Work Location: In person