Medical Records Assistant

Position Summary

The Medical Records Assistant is responsible for maintaining, organizing, and securing all resident health information in accordance with federal, state, and facility regulations. This position ensures timely and accurate documentation, assists with audits and surveys, and supports clinical and administrative staff in accessing necessary medical record information.

Essential Duties and Responsibilities

• Maintain and update resident medical records in compliance with HIPAA and facility policies.
• File, scan, and organize medical documents (admission records, physician orders, progress notes, discharge summaries, etc.).
• Process record requests from authorized parties such as physicians, hospitals, or family members.
• Assist with electronic health record (EHR) data entry, indexing, and quality checks.
• Ensure timely completion and accuracy of resident charts per state and federal regulations.
• Participate in audits, quality assurance programs, and survey preparation.
• Maintain confidentiality and secure access to all resident health information.
• Support nursing and administrative staff with chart retrieval and record-keeping needs.
• Manage record retention, archiving, and destruction according to policy.
• Perform clerical duties including copying, faxing, and filing as needed.

Qualifications

Education and Experience:

• High school diploma or equivalent required.
• Previous experience in medical records, health information management, or clerical work in a healthcare setting preferred.
• Experience in a skilled nursing facility or long-term care environment strongly preferred.

Skills and Abilities:

• Knowledge of medical terminology and basic anatomy.
• Familiarity with EHR systems (e.g., PointClickCare, MatrixCare, PCC, etc.).
• Excellent attention to detail and organizational skills.
• Ability to maintain confidentiality and comply with HIPAA regulations.
• Strong communication and interpersonal skills.
• Ability to work independently and manage multiple tasks efficiently.

Physical Requirements

• Prolonged periods sitting, standing, and using a computer.
• Ability to lift up to 25 pounds occasionally (files, boxes, etc.).
• Visual acuity sufficient to review records and computer screens.

Work Environment

• Professional office setting within a skilled nursing facility.
• Interaction with residents, families, staff, and outside agencies.
• Must adhere to infection control and safety procedures.

Equal Employment Opportunity

Vermont Healthcare Center is an equal opportunity employer and does not discriminate based on race, color, religion, sex, age, national origin, disability, or any other legally protected status.

Job Type: Full-time

Pay: $22.00 - $25.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Work Location: In person

Salary : $22 - $25