HIS•HEALTH

INFORMATION ASST. ACC

Care Center•Skilled Nursing Sacramento, CA Job Details $20•$23 an hour 11 hours ago Qualifications Medical terminology Full Job Description

JOB SUMMARY

The Health Information Assistant's main priority is maintaining the health records of the facility per policy and state/federal compliance regulations to ensure residents' records contribute to the quality of care. The Health Information Assistant reports to the HIM (Health Information Manager). This position is hourly (non-exempt).

ESSENTIAL JOB FUNCTIONS

: Assists the HIM with analyzing and evaluating medical records for in-house residents per State & Federal regulations, accepted professional standards, and facility policies and procedures to include both quantitative and qualitative auditing. Audits new admissions and discharges promptly per procedures. Performs quality auditing on care plans, licensed nurses notes, RAI, informed consent, PDSA; reports outstanding audits to the Director of Nursing and Administrator. Performs Quality Audits routinely including but not limited to: Skin, Diabetic, Foley Catheter, Bowel and Bladder Retraining, Restorative Nursing, Specialized Therapy, Change in Condition, Physical Restraints, and Psychotropic drug documentation. Sorts and scans medical documents into PCC. Files, maintains records, release of records per rules and regulations. Performs discharge chart process; arranges record in proper audit order; performs final audit/screening; follows up on deficiencies, closes records within 30 days of discharge. Provides oversight and facilitates the record destruction process. Maintains Medical Records Department/Services for the facility. Maintains primary & secondary medical records filing systems including storage, protection, and destruction of medical records. Maintains correspondence and medicolegal aspects of medical records. Compiles statistics; prepares miscellaneous records and reports. Assists physician & allied health personnel to complete medical records. Follows up on the Physician's Visit Control Log & Verbal Order Control. Maintains knowledge of computer system for medical records per daily data entry of physician's orders, new admissions and discharges Audits and monitors timeliness of RAI for EDT on an ongoing basis. Protect privacy and security of Health information and follows confidentiality and release of information procedures. Responsible for any audit process assigned by the Health Information Manager

QUALIFICATIONS

High school diploma or equivalent preferred. Must have knowledge of medical terminology and knowledge of clerical office practices. Knowledge of state and federal regulations including Title XXII and OBRA preferred. A minimum of one-year combined experience in skilled nursing or another related health care field preferred