Job Description

Position Summary

The 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.

Education, Experience, And Licensure Requirements

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

Specific Job Requirements

• 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
• Maintains professional working relationships with all associates, vendors, etc.
• Maintains confidentiality of all proprietary and/or confidential information
• Understand and follow company policies including harassment and compliance procedures
• Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training

Essential Functions

• 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

An Equal Opportunity Employer

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