Medical Records Assistant

Apple Valley Care Center -

Purpose : To assist in maintaining an organized, accurate and compliant health record system in accordance with California Title 22, federal regulations and facility policies. Supports the daily operations of the HIM department by performing clerical and technical tasks related to resident records and documentation management.

Qualifications :

High School Diploma or equivalent.

Knowledge of medical terminology.

Understanding of Title 22- Health Records, including content, organization and retention.

Basic computer skills; minimum 45 wpm / data entry.

Experience in a health information or long term care setting preferred.

Essential Duties :

Ability to work well with nursing, administrative and interdisciplinary staff.

Essential Duties and Responsibilities :

Assist with initiating and organizing admission, in-house and discharge charts.

File, scan and organize documents into the correct sections of the resident record (paper and electronic)

Ensure documents have proper resident identifiers and are in correct chronological order.

Maintain daily chart filing and overflow record organization.

Assist with chart thinning and retention schedules

Support discharge chart assembly, review and control log documentation.

Update the Master Patient Index, admission / discharge log and census tracking as assigned.

Enter and retrieve data using electronic health record systems( Point Click Care)

Provide clerical support for QAPI, audits, surveys and chart reviews.

Assist with release of information requests under supervision of the HIM.

Physical Requirements

Primary sedentary; requires walking, standing and lifting files ( up to 25 lbs)

Regular use of computer, scanner, copy machine and filing systems.