Unit Ward Clerk

Integritus Healthcare•South Yarmouth, MA

About The Position

Windsor has been part of the community since 1975, providing families with skilled nursing care for short-term rehabilitation and long-term care. We focus on maximizing patient recovery, comfort, and independence to support quality of life. Our experienced team offers compassionate, specialized care to reduce hospital readmissions and improve outcomes through rehab, long-term care, adult day health, and restorative services. Be part of a collaborative, caring team at Integritus Healthcare. We offer excellent benefits, including generous paid time off and exceptional health insurance – plus real opportunities to grow your career. If you’re ready to make a difference, we’d love to have you on board! Essential Job Functions: Assist in organizing, planning & directing the medical records section in accordance with established policies and procedures. Maintain a working rapport with other departments in the facility to assure that medical records can be properly maintained. Assist in recording all incidents/accidents. File in accordance with established policies and procedures. Collect, assemble, check, and file resident charts and personnel records as required. Ensure incomplete records/charts are returned to nursing service for correction. Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing. Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures. Maintain records of information taken from charts/records, i.e., type information, name of recipient, date, department, etc. Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. Maintain various registries as directed including register for admission and discharge of residents. Collect charts, assemble them in proper order, and inspect them for completion. Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed. Assist in admission, transfer and discharge procedures as necessary. Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary. Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies, etc.) Assure that medical records taken from the department are signed out and signed in upon return to the department. File active and inactive records in accordance with established policies. Index medical records as directed. Other duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.

Requirements

Must possess, as a minimum, a high school diploma or equivalent.
Must have knowledge of medical terminology
Must possess a current, unencumbered, active CNA license in this state.
Must be able to read, write, speak, and understand the English language.
Must possess the ability to make independent decisions when circumstances warrant such action.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
Must possess the ability to plan, organize, develop, implement, & interpret programs, goals, objectives, policies & procedures, etc., that are necessary for providing quality care.
Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
Will meet all physical requirements of the position as identified by the facility policies and procedures related to functional job analysis.

Responsibilities

Assist in organizing, planning & directing the medical records section in accordance with established policies and procedures.
Maintain a working rapport with other departments in the facility to assure that medical records can be properly maintained.
Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
Collect, assemble, check, and file resident charts and personnel records as required.
Ensure incomplete records/charts are returned to nursing service for correction.
Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
Maintain records of information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
Maintain various registries as directed including register for admission and discharge of residents.
Collect charts, assemble them in proper order, and inspect them for completion.
Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
Assist in admission, transfer and discharge procedures as necessary.
Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies, etc.)
Assure that medical records taken from the department are signed out and signed in upon return to the department.
File active and inactive records in accordance with established policies.
Index medical records as directed.
Other duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.