Health Information Assistant - Villas at the Cedars

Health Information Assistant

POSITION SUMMARY 

Under the direction of the Health Information Manager, the Health Information Assistant (HIA) is responsible  for monitoring and completing medical records for every resident in a way that maintains the integrity of the  health information system and ensures their accuracy, organization and accessibility. The HIA also performs  nursing station administrative functions that improve the delivery of care to residents.  

ESSENTIAL RESPONSIBILITIES AND DUTIES 

RECORDS MANAGEMENT 

Admission 

• Coordinate the admission process, ensuring it is comprehensive and resident-centered Initiate the inpatient medical record and in-house overflow file, prepares labels, etc. Complete admissions checklists; inputs admission data into system 

During Resident’s Stay 

• Thin in-house records in accordance with the written policy/procedure and file in chart order for  discharge in in-house overflow file 
• Maintains in-house chart appearance and organization 
• Maintains monitoring system to ensure phone order and other information is signed or returned by  physician and other professionals in a timely manner 
• Files incoming clinical information in the in-house records daily 
• Monitor timeliness of physician visits in conjunction with HIM; pull charts for physician rounds and  transcribe new orders, if applicable 
• Track and schedule routine labs 
• Schedule resident appointments and arrange transportation 
• Transcribe vitals, input/output information, per system 
• Prepare paperwork for transfer or referrals 
• Transcribes physician or NP orders obtained from clinical staff; signed off by clinical staff Discharge 
• Prepare paperwork for discharge and transfers 
• Assemble record from the nursing station and overflow file in established discharge order 

NURSING STATION 

• Answers phones 
• Maintains an organized nursing station 
• Maintains supply of all forms and clerical supplies 
• Maintains station lists 
• Completes filing 
• Assist family, visitors as needed and appropriate

QUALIFICATIONS 

Education and Experience 

• High School graduate or equivalent 
• Knowledge of medical terminology 
• Long-term care or healthcare experience 

Preferred 

• 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 and medical terminology 

Required Skills and Abilities 

• Empathy for elderly with ability to be sensitive to resident and family needs 
• Resilience; ability to provide/receive constructive feedback, course correct and not take it personally
• Motivator; ability to ensure staff feel supported while ensuring accountability to work expectations
• Personability; ability to get along with all personality types and inspire trust with residents, staff, family  and the community 
• High emotional intelligence (EQ) 
• Ability to actively listen, with the goal of understanding 
• Ability to clearly speak and proficiently read and write in English