Unit Clerk Full-Time

About the role

The Unit Clerk at Willow Creek Health Care Center supports nursing staff, maintains accurate records, coordinates communication, and helps the nursing unit operate efficiently. The primary purpose is to assist the Nurse Supervisor/Charge Nurse in recording and charting medical or administrative information.

Responsibilities

• Record medical and administrative information in accordance with established charting and documentation policies and procedures
• Maintain the Daily Census Report and submit to Nurse Supervisor/Charge Nurse
• Maintain an up-to-date roster of residents for your assigned unit
• Fill out resident charge slips and submit to the Business Office
• Answer telephone, page calls, deliver messages to residents, etc., as necessary
• Maintain a current listing of emergency phone numbers for your assigned unit
• Maintain and forward daily tardy and absentee reports to the Business Office
• Transcribe physicians’ orders to care plans, medication cards, treatment plans, etc., as required
• Report discrepancies found in transcribing physicians’ orders, diet orders/changes, charting, etc.
• Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, legibility, etc., as directed
• Chart nurses’ notes in an informative and descriptive manner that reflects the care provided as well as the resident’s response to the care
• Forward new diet orders and/or diet changes to the Director of Food Services
• Notify the resident’s next-of-kin when there is a change in the resident’s condition as instructed
• Admit, transfer, and discharge residents
• Absorb necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge
• Forward completed charts of discharged residents to the Medical Records/Health Information Department
• Attend various committee meetings of the facility (e.g., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment, etc.) as required
• Assist in developing work assignments, schedules, etc., as required
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility
• Greet newly admitted residents upon admission
• Encourage attending physicians to record and sign progress notes, physicians’ orders, etc., on a timely basis and in accordance with current regulations
• Inform family members of the death of a resident as instructed
• Call funeral homes when requested by the family
• Attend and participate in annual facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.)
• Participate in the implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases, including TB, among the residents and personnel
• Inform the Nurse Supervisor/Charge Nurse of your equipment and supply needs
• Ensure that all personnel involved in providing care to the resident are aware of the resident’s care plan and that nursing personnel refer to the resident’s care plan prior to administering daily care to the resident
• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
• Treat all residents fairly, and with kindness, dignity, and respect
• Absorb all incidents/accidents
• File in accordance with established policies and procedures
• Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator

Qualifications

• High school diploma or GED
• Exceptional communication and customer service skills
• Basic knowledge of medical terminology and nursing practices is helpful

Skills

• Medical terminology
• Nursing practices

Benefits

No specific benefits are mentioned in the job posting.

Pay

$18.00–$19.00+ per hour, based on experience

Schedule

No specific schedule is mentioned in the job posting.