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Full Job Description
The Medical Records Assistant maintains residents’ medical records in accordance with facility policies and with state and federal regulations.
Responsibilities
- Health Information:
o Set up medical records prior to admission. Monitor and audit records for completeness and accuracy at assigned intervals, in accordance with facility policy. Inform administrator and Director of Nursing Services of deficiencies in documentation.
o Provide information to the business office as required to meet admission requirements.
o Process and mail correspondence to physicians.
o May participate in monitoring of RAI, RAPS and Care Plan. Process, transfer, and discharge records and maintain appropriate records on discharged residents.
o Organize, file and store medical records according to facility policy and procedure and regulations.
o Assure confidentiality of medical record information. Prepare reports, statistics and records as directed by the administrator and/or Director of Nursing Services and provide records to interdisciplinary conferences when requested.
o Audit records prior to interdisciplinary conference so that deficiencies can be corrected.
Required Education and Experience
- Must have related administrative experience and/or experience as CNA or Nurse at a level necessary to accomplish the job.
- Must have training and/or certification or experience as required by the state.
- Ability to adapt to a flexible work schedule.
- Ability to relate positively, effectively, and appropriately with residents, families, community members, volunteers, and other facility staff.
- Possess a special interest in, and a positive attitude about, working with long-term care residents and the elderly.
- Ability to read, write, speak, and understand English.
- Must be able to maintain regular attendance.
- Meet all health requirements, as required by law.
- Demonstrate basic computer knowledge and ability with an aptitude to learn company applications.
- Demonstrate understanding of State and Federal rules and regulations that govern the practices within the
