Hybrid Medical Records Assistant Yuma Hourly chez Haven Health

The Medical Records Assistant works under the direction of the medical records manager to ensure all medical records are managed in accordance with Company policy and state and federal regulations. The Medical Records Assistant is responsible for the execution and completion of assignments from the Medical Records Manager ensuring that all protected health information is safeguarded as required by Company policy and HIPAA. The Medical Records Assistant works closely with the nursing department to ensure accurate and complete medical records are kept for all residents.

Role & Responsibilities

• Properly register residents in the necessary medical records, logs and files in the facility including but not limited to, admissions and discharge logs, clinical information software programs and other logs used at the facility.   
• Maintain filing system for health records that meets the needs of the facility, including overflow files for current residents and health records of discharged residents.
• Confirm that all appropriate transfer and admission paperwork has been completed; contact transferring facility or entity for additional information as needed.
• Request the history and physical exams for residents and obtain an updated and original signature.
• Collect and process all telephone orders for mailing; ensure that all orders are signed by physicians and dated before updating them in the medical record; daily review of the telephone orders and admit orders for accuracy.
• Review clinical software for upcoming MDS assessments and care plan reviews; monitor that MDS and assessments (UDA) are completed timely.