Health Information Assistant
On-siteChisago City, Minnesota, United States
Job Summary
Coordinate comprehensive, resident-centered admissions, initiate medical records, and accurately enter admission data into the system. Maintain organized, accurate in-house medical records by filing clinical information daily and ensuring proper chart order. Monitor and follow up on physician orders, phone orders, and required signatures to ensure timely completion and compliance. Track routine labs, schedule resident appointments, arrange transportation, pull charts for physician rounds, and enter vitals and intake/output data. Prepare and process paperwork for referrals, transfers, and care coordination while ensuring accurate transcription of physician and NP orders. Prepare discharge and transfer documentation and assemble complete medical records from nursing stations and overflow files according to established discharge procedures.
Required Qualifications
- High School graduate or equivalent
- Knowledge of medical terminology
- Long-term care or healthcare experience
- Previous experience as a health office secretary
- Training in medical records
- Experience with coding
- Knowledge of regulations, documentation requirements and legal issues
- Previous experience transcribing physician orders
- Knowledge of medications
- Knowledge of medical terminology
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