Visalia Post Acute
Location: Visalia, CA
Pay Rate: $17.48 per hour
Schedule: Full-Time
Skilled Nursing Facility (SNF)

The primary purpose of the Medical Records Assistant is to maintain resident medical records and health information systems in compliance with federal and state regulations, as well as facility privacy policies and procedures. This role supports accurate documentation, confidentiality, and timely access to resident health information.

Administrative Functions

• Receive and follow work schedules and instructions per facility policies

• Assist in organizing, planning, and directing medical records operations

• Support the Medical Records/Health Information Consultant as needed

• Maintain meeting minutes and file appropriately

• Maintain effective working relationships with all departments

• Retrieve, assemble, audit, and file resident medical records (manual and electronic)

• File nurses’ notes, assessments, progress notes, lab reports, imaging results, and correspondence

• Collect, assemble, and inspect charts for completeness and accuracy

• Assist the MDS Coordinator with scheduling assessments per OBRA guidelines

• Ensure incomplete records are returned for correction

• Track authorized release of information and maintain release logs

• Abstract and index information for Medicare, Medicaid, VA, insurance, and authorized entities

• Maintain admission/discharge registries and other required logs

• Transcribe and type physician reports as needed

• Answer medical records–related inquiries and prepare correspondence

• Ensure charts leaving the department are properly signed out and returned

• Maintain confidentiality and comply with HIPAA and facility privacy standards

• Report suspected or known unauthorized access or disclosure immediately

Committee Functions

• Provide secretarial support to committees as directed

• Compile records and prepare reports for committee review

Personnel / Compliance

• Report suspected fraud or abuse per policy

• Ensure unattended workstations are logged off or secured

Staff Development

• Attend required in-service training (OSHA, TB, HIPAA, Abuse Prevention, etc.)

• Participate in approved workshops and seminars

Safety, Equipment, and Supplies

• Report unsafe conditions or equipment issues promptly

• Ensure adequate supplies and orderly work areas

Other duties as assigned

• This position carries administrative authority and accountability for assigned duties

• No direct supervisory responsibilities

Education & Experience

• High school diploma or GED required

• Ability to type 45 WPM and use dictation equipment

• Knowledge of medical terminology required; anatomy, physiology, coding, indexing preferred

• Computer proficiency (data entry, retrieval, EMR)

• On-the-job training provided

Language Skills

• Ability to read, write, speak, and understand English

• Ability to read technical procedures and policy manuals

Mathematical & Reasoning Skills

• Ability to apply basic math concepts

• Ability to make independent decisions, follow written/oral instructions, and work tactfully with others

• Ability to move throughout the workday

• Ability to lift/push/pull up to 25 pounds

• Ability to cope with mental and emotional demands of the role

• Visual and hearing ability (with or without accommodation) sufficient to perform duties

• May assist in resident evacuation during emergencies

• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions

• Office and facility-wide environment with frequent interruptions

• May require weekends, holidays, or extended hours as needed

• Exposure to healthcare-related risks, including infectious materials

• Reasonable accommodations available

This description does not limit management’s right to assign or reassign duties at any time. The duties listed describe the general nature and level of work and are not intended to be exhaustive.

Visalia Post Acute is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected status in accordance with applicable laws.