Medical Records Assistant (Non Nurse)

Assists with patients’ clinical records, including coding, auditing, and record management in accordance with all applicable laws, regulations, and Life Care standards.

Requirements

• High school diploma or equivalent
• Prior medical records experience preferred

Responsibilities

• Demonstrate knowledge of State and Federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information
• Effectively communicate with physicians, nursing staff, and allied health personnel
• Demonstrate efficient usage of complex computer software systems
• Functional knowledge in field of practice
• Make independent decisions when circumstances warrant such action
• Knowledgeable of practices and procedures as well as the laws, regulations, and guidelines governing functions in the post acute care facility
• Implement and interpret the programs, goals, objectives, policies, and procedures of the department
• Perform proficiently in all competency areas including but not limited to: patient rights, and safety and sanitation
• Maintain professional working relationships with all associates, vendors, etc.
• Maintain confidentiality of all proprietary and/or confidential information
• Understand and follow company policies including harassment and compliance procedures
• Display integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training
• Accurately audit and complete ongoing reviews of all patients’ clinical records to ensure documentation and performance compliance
• Accurately maintain current, overflow, and discharged record filing system
• Understand and apply LTC payment systems, including Medicare
• Apply the use of ICD 10 CM coding
• Understanding of HIPAA requirements
• Exhibit excellent customer service and a positive attitude towards patients
• Assist in the evacuation of patients
• Demonstrate dependable, regular attendance
• Concentrate and use reasoning skills and good judgment
• Communicate and function productively on an interdisciplinary team
• Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
• Read, write, speak, and understand the English language