Unit Clerk Full-Time

Pay Range: $18.00-$19.00+ per hour, based on experience

About the role

The primary purpose of your job position is to assist the Nurse Supervisor/Charge Nurse in their day-to-day recording and charting of medical or administrative information in accordance with current federal, state, and local standards, guidelines, and regulations that govern medical records. This role ensures that medical records are maintained in an informative and descriptive manner.

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.
• Record appropriate resident identification data on designated medical records, wristbands, ID cards, etc., as required.
• 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., to the Nurse Supervisor/Charge Nurse.
• Review medication cards for completeness of information, accuracy in transcription, legibility, etc., as directed.
• Chart nurses' notes in an informative and descriptive manner reflecting the care provided and the resident's response.
• 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, including arranging transportation, packing belongings, and escorting residents.
• Complete necessary medical and administrative records upon admission, transfer, and/or discharge of residents.
• Forward completed charts of discharged residents to the Medical Records/Health Information Department.
• Attend various facility committee meetings (e.g., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment).
• Assist the Nurse Supervisor/Charge Nurse in developing work assignments and schedules.
• Develop and maintain good working rapport with inter-departmental personnel and other departments.
• Inform nursing service personnel of new admissions, expected arrival times, and room assignments.
• Greet newly admitted residents and escort them to their rooms as necessary.
• Encourage attending physicians to record and sign progress notes, orders, etc., on a timely basis.
• Inform family members of a resident's death as instructed and call funeral homes when requested.
• Attend and participate in annual facility in-service training programs (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control).
• Participate in training programs prior to tasks involving potential exposure to blood/body fluids.
• Participate in the implementation and maintenance of the infection control program for monitoring communicable/infectious diseases.
• Inform the Nurse Supervisor/Charge Nurse of equipment and supply needs.
• Ensure all personnel are aware of the resident's care plan and refer to it prior to administering care.
• Report suspected or known incidence of fraud relative to false billings, cost reports, or kickbacks.
• Treat all residents with kindness, dignity, and respect.
• Assist in recording all incidents/accidents and file in accordance with policies.
• Agree not to disclose residents' protected health information and report suspected violations.
• Perform other duties as assigned by the supervisor, Director of Nursing, or Administrator.

Requirements

• Must possess, as a minimum, a high school diploma or GED.
• Exceptional communication and customer service skills.
• Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions from managers and employees.
• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
• Ability to solve practical problems and deal with variables in situations with limited standardization.
• Ability to interpret instructions furnished in written, oral, diagram, or schedule form.
• Basic knowledge of medical terminology and nursing practices is helpful.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

• Occasionally lift and/or move up to 25 pounds.
• Prolonged use of a desktop or laptop computer.
• Regularly required to sit, stand, walk, talk, read, or hear.
• Frequent use of office equipment such as copier, scanner, fax, telephone, and calculator.
• May assist in the evacuation of residents during emergency situations.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

• The noise level in the work environment is usually low to moderate.