Ward Clerk Full-Time

PACS

8d•$17 - $18•Onsite

About The Position

The primary purpose of this position is to assist the Nurse Supervisor/Charge Nurse in the day-to-day recording and charting of medical and administrative information in accordance with current federal, state, and local standards, guidelines, and regulations governing medical records. This role ensures that medical records are maintained in an accurate, informative, and timely manner. Every effort has been made to identify the essential functions of this position. However, this does not imply that these are the only duties required. The omission of specific duties does not exclude work that is similar, related, or an essential function of the position.

Requirements

High school diploma or GED required
Strong communication and customer service skills required
Ability to read, analyze, and interpret documents such as policies, procedures, and regulations
Ability to write reports and correspondence
Ability to effectively communicate with staff, residents, and families
Ability to apply basic mathematical concepts such as fractions, percentages, and ratios
Ability to solve practical problems and interpret a variety of instructions
Ability to sit, stand, and walk throughout the workday
Frequent use of computers, phones, and office equipment
Ability to lift and/or move up to 25 pounds occasionally
May be required to assist during emergency situations

Nice To Haves

Prior healthcare or skilled nursing experience preferred
Basic knowledge of medical terminology preferred
Basic knowledge of medical terminology and nursing practices preferred

Responsibilities

Record medical and administrative information in accordance with established policies and procedures
Maintain Daily Census Reports and submit to Nurse Supervisor/Charge Nurse
Maintain an up-to-date resident roster for the assigned unit
Complete resident charge slips and submit to the Business Office
Answer telephones, page calls, and deliver messages as needed
Maintain current emergency contact lists for the unit
Track and forward tardy and absentee reports to the Business Office
Record resident identification data on medical records, wristbands, and ID cards
Accurately transcribe physicians’ orders to care plans, medication records, and treatment plans
Report discrepancies in orders, charting, or documentation to the Nurse Supervisor/Charge Nurse
Review medication cards for accuracy, completeness, and legibility
Document nurses’ notes in an informative and descriptive manner
Forward diet orders and changes to the Dietary Department
Notify family members of changes in resident condition as directed
Assist with resident admissions, transfers, and discharges, including documentation and coordination
Prepare and forward discharged resident charts to Medical Records
Participate in facility committees and meetings as required
Assist with staffing schedules and assignments as directed
Maintain positive working relationships with all departments
Communicate new admissions and updates to nursing staff
Greet and assist new residents upon admission
Encourage timely physician documentation in accordance with regulations
Notify families and coordinate services (e.g., funeral homes) as directed
Participate in required in-service training programs (OSHA, HIPAA, Infection Control, etc.)
Support infection control practices and reporting
Ensure care plan awareness among staff and support compliance
Report suspected fraud, compliance concerns, or irregularities
Treat all residents with dignity, respect, and compassion
Assist with incident/accident reporting per policy
Maintain strict confidentiality of resident information (HIPAA compliance)
Perform other duties as assigned by Supervisor, DON, or Administrator