Medical Records Assistant (Healthcare)

Position Summary

The Medical Records Assistant plays a vital role in maintaining accurate, organized, and confidential health records for all residents in accordance with facility policies and HIPAA regulations. This position supports the daily operations of the medical records department, ensures compliance with federal and state guidelines, and facilitates communication between departments.

Essential Responsibilities

• Follow assigned work schedules and instructions in line with facility policies.
• Assist with organizing, planning, and directing the medical records department.
• Support the Medical Records Director as needed.
• Maintain and file meeting minutes and documentation.
• Develop strong working relationships with interdepartmental staff to ensure proper documentation management.
• Record, track, and file incidents and accidents as required.
• Retrieve, deliver, and organize resident records both manually and electronically.
• File clinical documentation (nurse notes, assessments, progress notes, lab results, imaging, correspondence, etc.) into resident charts.
• Collect, assemble, and review charts for accuracy and completeness.
• Support MDS Coordinator in scheduling assessments per facility and OBRA guidelines.
• Ensure incomplete or inaccurate records are returned for correction.
• Maintain procedures to ensure chart integrity, privacy, and security.
• Log authorized release of resident information per HIPAA and Privacy Rules.
• Index records and maintain registries for admissions and discharges.
• Transcribe physician reports and other clinical documentation.
• Respond to internal and external medical record inquiries.
• Prepare written correspondence as needed.
• Maintain accurate sign-in/out logs for chart access.
• Organize and file active and inactive records.
• Monitor, maintain, and restock supplies and report equipment issues.
• Maintain a clean, organized work area.

Compliance and Confidentiality

• Maintain confidentiality of resident records and facility data.
• Promptly report any suspected breaches of confidentiality or unauthorized access.
• Comply with all HIPAA, OSHA, TB, and Abuse Prevention regulations.

Committee & Administrative Support

• Provide secretarial support for facility committees.
• Compile and prepare documentation for committee review and reporting.

Staff Development

• Attend mandatory in-service training and professional development workshops.

Safety & Emergency Preparedness

• Report hazardous conditions or defective equipment immediately.
• Participate in emergency preparedness drills and assist with resident evacuation if needed.

Supervisory Responsibility

• While this role does not include direct supervision, the position holds administrative responsibility for completing all assigned duties accurately and timely.

Qualifications

Education & Experience:

• High school diploma or GED required.
• Ability to type a minimum of 45 WPM.
• Prior experience with health information management preferred.
• Familiarity with medical terminology, anatomy, and legal aspects of medical records is a plus.
• On-the-job training provided.

Technical Skills:

• Proficient in computer use, including data entry and retrieval.
• Experience with electronic medical records (EMR) systems preferred.

Language & Communication:

• Must be able to read, write, speak, and understand English.
• Strong written and verbal communication skills.

Mathematical Skills:

• Ability to apply basic math concepts such as ratios and percentages.

Reasoning & Interpersonal Skills:

• Ability to work independently and make sound decisions.
• Professional and respectful communication with residents, families, and staff.
• Adaptable to new technologies and workflows.

Physical Requirements

• Must be able to move intermittently throughout the workday.
• Capable of lifting up to 25 lbs and moving charts and supplies as needed.
• Must meet general health requirements, including a physical exam.
• Ability to handle mental/emotional stress in a fast-paced environment.

Work Environment

• Office setting within a healthcare facility.
• Exposure to residents, family members, staff, and occasionally infectious conditions.
• May require working weekends, holidays, or additional hours during emergencies.

Note: This job description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the position. Management reserves the right to revise and assign additional duties as needed.