Medical Records Assistant - Part Time (Healthcare)

Job Title: Medical Records Assistant

Job Summary

The Medical Records Assistant is responsible for organizing, maintaining, and protecting resident health information, ensuring accuracy, confidentiality, and compliance with all established policies and federal regulations, including HIPAA. This role involves managing both physical and electronic health records (EHR) and providing administrative support to the Medical Records department.

Record Management:

File and retrieve resident records, both manual charts and electronic records, in an accurate and timely manner.

Digitize paper records and enter data into the computer system, ensuring the integrity and security of all electronic records.

Collect, assemble, inspect, and organize resident charts with information such as nurses' notes, assessments, lab reports, and correspondence.

Coordinate with the MDS Coordinator to schedule assessments according to facility and OBRA guidelines.

Return incomplete charts or records to the appropriate personnel for correction and follow up to ensure completion.

Administrative Duties:

Maintain various registries, such as admission and discharge logs.

Perform secretarial duties for facility committees, including preparing reports and maintaining minutes of meetings.

Draft and prepare written correspondence as necessary.

Answer and screen telephone inquiries related to medical records.

Compliance and Security:

Adhere strictly to all HIPAA regulations and facility policies to protect resident protected health information (PHI).

Maintain a record of all authorized information released from resident charts.

Ensure that records taken from the department are signed out and properly returned.

Immediately report any suspected or known unauthorized access, fraud, or violations of privacy to the Administrator.

Interdepartmental Support:

Develop and maintain a good working relationship with all facility personnel to ensure effective communication.

Retrieve and deliver medical records to authorized personnel, including physicians, nurses, and government agencies.

Abstract information from records for insurance companies, Medicare, Medicaid, and the VA, following Privacy Rules.

Assist in collecting and compiling records for committee review and audits.

Qualifications

• High school diploma or GED required.
• Ability to type at least 45 words per minute.
• Proficiency with computers and electronic health record (EHR) systems.
• Knowledge of medical terminology, anatomy, and physiology is preferred.
• Experience in a medical office setting is a plus, but on-the-job training is provided.
• Familiarity with medical records and health information system procedures.
• Knowledge of HIPAA compliance requirements.
• Excellent organizational skills and attention to detail.
• Strong verbal and written communication skills in English.