Medical Records Assistant

Job Details: Level: Entry, Job Location: Almond Vista Healthcare

• Modesto, CA, Salary Range: $17.50 - $18.50Hourly, ESSENTIAL JOB FUNCTIONS:
• Transcribe, accurately, physician and nursing orders on appropriate documents in a timely manner
• Keys information into computer systems, including EMR
• Assure that nursing staff and other staff, as appropriate, is aware of new orders and notes them as required
• Record accurate, legible information about resident care and condition in appropriate sections of resident’s records
• Follow facility policies and procedures including those related to infection control
• Capable to perform new duties as assigned and trained
• Maintain resident medical charts, station documents and supplies
• Input physician and nursing orders to computer
• Establish and maintain effective communication both written and verbal
• Able to interact effectively with individuals who are cognitively and/or physically impaired
• Organize nursing stations and maintain a tidy work environment
• Perform chart audits as assigned
• Demonstrate ability to maintain confidentiality of resident and facility information
• Prioritize workload and complete projects accurately and in a timely manner
• Assist with preparation for state inspections as directed. Attend survey training and interact with state surveyors as directed by immediate supervisor
• Demonstrate interpersonal skills that contribute to a positive work environment
• Demonstrate knowledge of and a respect for the right, dignity and individuality of each resident in all interactions
• Provide excellent service to staff, visitors, and residents
• Answer telephone professionally and in accordance with facility policy
• Demonstrate competence in use of proper body mechanics for both upper and lower body
• Monitor physical environment for safety or fire hazards and corrects or reports potential problems immediately to Charge Nurse. Promptly reports housekeeping and maintenance problems to Charge Nurse
• Report injury to resident or self to Charge Nurse immediately
• Participate in fire and disaster drills. In the event of any emergency, carries out assigned duties to assure resident safety
• Knowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond to written or oral instruction in case of emergency
• Adhere to policies and procedures JOB FUNCTIONS:
• Demonstrate knowledge of, and respect for, the rights, dignity and individuality of each resident in all interactions
• Appreciates the importance of maintaining confidentiality of resident and facility information
• Demonstrate honesty and integrity at all times in the care and use of resident and facility property
• Must be able to key information into computer systems
• Good communication skills both verbal and written
• Proficient in English
• Able to understand and follow written and verbal directions
• Working knowledge of basic computer programs: Word and Excel
• Basic and advanced typing
• Basic and advanced filing
• Working knowledge of medical terminology
• Open, flexibility to changing needs of the Medical Records Department
• Other duties as assigned Qualifications: QUALIFICATIONS/REQUIREMENTS: Education: High School graduate or equivalent License: None Required Work Experience: Previous experience in medical records preferred Language Skills:
• Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language. Mathematical Skills:
• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to perform these operations using units of weight measurement, and volume. Communication Skills:
• Must have exceptional communication and customer service skills, and be empathetic.
• Ability to effectively communicate with patients, families, responsible parties, staff and outside resources and agencies.