Medical Records Administrative Assistant

Job Title:  Medical Records Administrative Assistant

Qualifications:  High School Diploma or GED; Computer and typing skills; Organization skills; Submitting to and passing successfully a criminal record check and a drug screening test.

Hours: Monday through Friday 8:00 am until 4:30 pm   Evening and weekend hours may be required.

This position reports directly to the Medical Records Librarian, Team Leader, and/or Program Director, if in a Residential Program.

Summary of Job Duties:  This position requires the employee to provide administrative support to the outpatient behavioral health office regarding the policies and procedures governing Medical Records.  This person is responsible for assisting clinical staff on the correct procedures for filing Medical Records information, time frames regarding documentation, correct procedures for completion of the billing document and the staff notes, HIPPA compliance and releasing medical information. Additionally, this person is responsible for maintaining the Medical Records per Agency’s policies and procedure.

Essential Duties and Responsibilities:

Include the following:

• Assist in planning, organizing, directing and evaluating the overall operation of the Medical Record Program.
• Assisting in policy, procedure and system development and implementation for the overall operation of Medical Records.
• Assist with keeping staff informed of new changes and relevant issues.
• Ensures the accuracy, content and completeness of all client files.
• Assist with the overall operation of the outpatient intake office by providing relief and coverage.

• Responsible for coding diagnoses and ensuring current diagnosis is on the Chronological Summary in the medical record.
• Maintaining and establishing Client II Medical Record Files.
• Responsible for ensuring completeness of terminated files prior to storage.
• Responsible for copying files for Social Security Disability and attorneys.  Copies of Medical Records files may be given to the consumer, if requested.
• Responsible for the daily filing and maintenance of the medical record.
• Responsible for pulling all Medical Records for the outpatient clinicians including those to be seen on the next day.
• Able to locate all Medical Records for those consumers who are being served at the site.
• Responsible for transporting all terminated Medical Records to the appropriate storage facility when the record is no longer required in the outpatient office per agency’s policy.
• Responsible for maintaining the confidentiality of all Medical Records.

• Refrains from assuming any duty that is unrelated to and/or interferes with the responsibilities of the position.
• Responds to an emergency situation in a timely fashion.
• Responsible for conducting monthly inspections of the Medication Storage area and Medication Sign In/Sign Out logs for all sample medication.
• Responsible for sending all outdated medications to the appropriate Regional Site for disposal.  Disposing of all medication is documented by completion of log of medications.
• Demonstrates the ability to work effectively with other team members, as part of a multidisciplinary team, and independently, when necessary.
• Other duties may be assigned when necessary.

Required Job Skills:

• Oral and Written Communication Skills
• Interpersonal Skills
• Ability to exercise good judgment, tact, diplomacy and compassion when problem solving, handling conflict or in a crisis situation
• Ability to complete record keeping in a timely fashion
• Ability to get along with diverse personalities and maintain effective working relationships
• Ability to work well with people of all races, backgrounds and needs
• Ability to work as part of a comprehensive community mental health team and to positively represent the agency in the community

Additional Responsibilities:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations will be made to enable the individual with disabilities to perform the essential functions.

• Physically able to reach, push, pull, bend,  stoop, stand, walk and lift up to 20 pounds
• Possess a valid Driver’s License and maintain a safe driving record if required for job performance.
• Apply and receive a certificate for being a Notary in the State of Kentucky if required for job.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations must be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee occasionally works in outside weather conditions, may be off-site from normal office location or placed at a Residential Program.

The noise level in the work environment is mild to moderate.

Environmental Data and Job Hazards:

• Hours of work are structured 7.5 or 8.0 hour blocks of time but may be subject to irregular and/or flexible hours based on needs or demands.
• Position may require duties to include routine or reasonable anticipated tasks or procedures where there is a degree of actual or potential exposure to blood or other infectious materials.
• All staff are required to participate in yearly trainings regarding infection control and safety in the environment including hazardous waste and blood borne pathogens.
• All new staff must attend training regarding handling physical, verbal threats, acts of violence or other escalating and potential dangerous situations including when police need to be summoned.

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