Medical Records/Health Information Associate - PT

Job Description

Description
Notre Dame Health Care, the operator of a five-star rated rehab and long term care center, assisted living residence, memory care units, Medicare licensed hospice, palliative and pediatric care programs, care management program, and an educational center, all located in Worcester, MA seeks a Medical Records/Health Information Associate to work in our nursing Department in the Long Term Care facility.

Responsibilities:

• Follow and maintain HIPAA guidelines and regulations with respect to all resident information. Protect the security of medical records to ensure that confidentiality is maintained.
• Utilize and navigate resident information in the electronic or paper health record.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
• Accurately scan, upload, and save/attach documents to the appropriate electronic medical record.
• Complete admission chart set-up for each resident admission including, but not limited to, acquire resident history documentation and admission paperwork, set-up medical record file, and ensure documentation is filed according to department protocols.
• Process discharge records including chart is in proper order, ensure required signatures are complete, collate overflow record material, and secure the proper labeling and filing of records.
• Retrieve medical records when requested by authorized personnel (i.e. physicians, nurses, government agencies and personnel, etc.).
• Maintain adequate level of blank forms that are used on the nursing units.
• Assists on the units with filing in the paper medical record.
• Employee will be back up for Central Supply staff.

PM17.

Requirements:

• High School diploma or equivalent required.
• Minimum 2-5 years experience working within a medical records in Long Term Care setting required. Knowledge of ICD-10 CM coding preferred.
• Intermediate to advanced proficiency with Microsoft Office (Excel, Word) required.
• Strong computer/data entry/typing skills including the uploading/scanning and electronic storage of files required. Strong interpersonal, communication, and customer service skills required.
• Excellent analytical skills and judgment to interpret data and take appropriate action in circumstances and situations that vary required.
• Strong attention to detail, commitment to excellence and strong planning and organizational skills, using time efficiently and prioritizing and coordinating tasks appropriately required.
• Must be able to work with interdisciplinary departments.

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