PT Medical Records Assistant

JOB SUMMARY:

The primary purpose of the Medical Records Assistant is to provide support to the Medical Records Nurse, the organization, maintenance, and security of medical records in compliance with federal, state, and facility policies. This role ensures timely and accurate filing, retrieval, and documentation of patient health information.

JOB DUTIES & RESPONSIBILITIES:

Administrative Functions

• Maintain and organize active and discharged medical records in compliance with HIPAA regulations.

• File clinical documentation into patient charts promptly and accurately (paper and/or electronic health records).

• Ensure all required documentation is present, complete, and signed in accordance with facility policy and applicable regulations.

• Prepare records for audits, state surveys, and regulatory inspections.

• Track, log, and process medical record requests from external parties (e.g., hospitals, insurance companies, legal entities) with appropriate authorization.

• Assist in assembling new resident charts and archiving discharged resident charts according to retention policies.

• Monitor timely completion of physician signatures and charting requirements.

• Support scanning, indexing, and electronic filing of documents into EMR systems.

• Communicate with nursing and administrative staff to ensure accurate and updated documentation.

• Assist with maintaining logbooks, forms inventory, and other clerical tasks related to health information management.

JOB REQUIREMENTS:

Education

• LPN license preferred, CNA also considered

• Some business training preferred

• Medical Records certification preferred Experience

• Must have two (2) years’ experience in medical records.

• Must have a minimum of six (6) months of experience in a health care environment

• Must have a typing speed of 45 wpm or greater

• Must be familiar with Windows computer environment

• Must have general office and clerical skills

• Must have excellent communication and interpersonal skills

• Must possess a practical knowledge of medical terminology and record keeping

• Must be organized and detailed in work performance

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