Medical Records Assistant

Duties and Responsibilities

Duties and Responsibilities will include, but may not be limited to:

• Supports audit readiness; prepares clinical documentation in accordance with audit record requests
• Requests records from accounts (facilities) and provide instruction to review, prior to submission
• Informs accounts of level of care guidelines and medical necessity criteria expected
• Reviews clinical documentation for medical necessity and level of care criteria accuracy
• Adheres to strict medical record checklists when conducting audits
• Prioritizes record requests based on original date requested and type of request(s)
• Notifies accounts (facilities) of deficiencies in medical necessity or attendance
• Communicates missing attendance to the billing department and ensures a corrected claim is submitted with appropriate records, if necessary
• Informs supervisor of weak clinical documentation and/or ongoing significant documentation deficiencies
• Follows up with accounts regularly to ensure records are reviewed and submitted in a timely manner
• Prepares and submits records via email, fax, or priority mail
• Downloads, collects, and files documentation from EMR systems
• Owns organization and tracking of all record submissions
• Updates billing software with mailing addresses, tracking #s, submission dates, etc.
• Verifies all facility/staff licenses and certifications are valid and current, prior to record submission
• Collects and securely files/stores facility/staff licenses and certifications on each account
• Drafts cover letters included with record submissions
• Prints claim forms to include with record submissions

Minimum Requirements

KNOWLEDGE

• High school diploma required; college degree preferred
• Two years’ experience in medical billing, OR two years’ experience working directly with substance abuse and/or mental health treatment centers
• Working knowledge of medical terminology, levels of care, ASAM, and insurance relating to substance abuse/mental health
• Familiar with HIPAA, JCAHO, and DHCS policies
• Familiar with EMR (electronic medical records) systems such as (Kipu, Best Notes, Zen Charts, etc.)
• Proficient with MS Office Suite (word processing, email, etc.)

SOFT-SKILLS

• Enjoys working in a collaborative environment 
• Works with a sense of duty – values strong attention to detail 
• Works with a sense of urgency as these documents are often time-sensitive 
• Ability to multitask, prioritize, and remain organized 
• Excellent interpersonal skills and strong communication 
• A desire to help people in a meaningful way