Under the direction of the Medical Records Manager, creates and maintains resident medical records for the facility. Ensures completeness and accuracy of medical records.

Note: All employees of Cascadia Healthcare are required to submit and be cleared to work in the facility per each

state’s specific background check requirements prior to contact with patients/residents.

Essential Functions

• Assists to ensure medical records are complete, with coordination of electronic function & scanning of hard copy records.
• Completes tasks as directed by the Medical Records Manager.
• Assists with audits of medical records as directed.
• Completes data entry into the electronic medical record as directed.
• Compiles statistical data such as admissions, discharges, deaths,.
• Operates a computer to enter and retrieve data, type correspondence and produce reports.
• Files documents, in accordance with established procedures.
• Maintains, retains and archives files in accordance with company policy and state and federal regulations.
• Ensures punctuality and regular attendance for assigned shifts.

Other Functions

• Performs other tasks as assigned.
• Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, applicable federal and state laws, and applicable professional standards.

Knowledge/Skills/Abilities

• Knowledge of medical terminology.
• PCC proficiency.
• Ability to be accurate, concise and detail-oriented.
• Ability to communicate effectively with residents and their family members, and at all levels of the organization.
• Knowledge of resident information and HIPAA privacy regulations.

Education

• High school diploma or equivalent required.

Licenses/Certification

• None required.

Experience

• Six months experience in a long-term care environment preferred.
• PCC experience preferred.
• One year experience as a Medical Records Clerk or with recordkeeping responsibility in a healthcare environment.