Unit Secretary/Medical Records Clerk

Job Description

Unit Secretary / Medical Records Clerk

Chase Memorial Nursing Home and Rehab – Good Shepherd Communities

Full-Time | Monday–Friday | 8:00 AM – 4:30 PM

Are you organized, detail-oriented, and looking for an opportunity to make a difference in healthcare? Chase Memorial Nursing Home and Rehab is seeking a dependable and motivated Unit Secretary / Medical Records Clerk to join our team!

In this important role, you will help maintain accurate medical records, provide essential clerical support to nursing staff, and assist with the daily operations of our healthcare facility. If you enjoy working in a team-oriented environment and understand the importance of accuracy, confidentiality, and excellent communication, we encourage you to apply!

Position Overview

The Unit Secretary / Medical Records Clerk compiles, processes, and maintains resident medical records in accordance with applicable medical, administrative, ethical, legal, and regulatory requirements. This position provides clerical support to nursing and administrative staff, helping ensure the efficient operation of the facility and allowing our team to focus on quality resident care.

Key Responsibilities

• Acts as a clerical liaison for the nursing units.

• Answers telephone for nurses’ station & team centers

• Deliver mail and newspapers to residents

• Prepare and track labs and x-rays to be done

• Obtain medical records from the RHIO as directed

• Prepare electronic medical record (EMR) for physician visits, ensuring all recent lab work and medical reports are signed and scanned for provider’s reference

• Monitor timeliness of physician visits on a weekly basis in conjunction with HIM Department Staff

• Schedule resident follow-up/routine appointments and arrange transportation upon request from nursing

• Prepare required paperwork for all resident appointments outside facility

• Make copies of medical records as directed

• Update nursing report sheets and maintain adequate documentation forms on the nursing units

• Track and print transcription

• Maintain adequate inventory of clerical supplies on nursing units

• Maintain the Master Patient Index on discharge

• Maintenance of the medical record

• Upon admission and readmission:

A. Update EMR on admission and readmission according to procedure

o Prepare ID labels, ID bracelet, disaster tag, transfer packets, and lab schedule sheet; verify advance directives in EMR; and take resident’s photo

o Ensure all documents have been received from the transferring facility

o Notify appropriate staff of documents not received

o Scan all paperwork on admission and readmission according to procedure

o Check eMOLST registry for resident record

o Enter consents for RHIO into EMR

B. Coordinate paperwork for discharge

o Copy all scripts and scan into EMR

o Copy Interdisciplinary Discharge Summary, scan into EMR and fax to appropriate agencies

o Assemble paper chart (ALR) in proper discharge order and file in ALR office

C. General maintenance:

o Update charts daily, all incoming clinical information into the EMR. Provide quality checks to ensure accurate and complete

o Conduct limited record analysis as directed by the H.I.M. Manager/ Director

o Complete periodic thinning of paper charts (ALR) as per established guidelines

• Coordinate and maintain Podiatry and Dental schedule. Track and report dental and podiatry statistics for SNF residents

• Participate in departmental QI as directed

• Provide coverage of other unit secretaries’ duties in their absence

• Competencies & Education

o Performs competencies to keep skills up to date & current

o Completes all Healthcare Academy courses and on-going education as required

o Attends in-services as required

Qualifications and Skills

• Strong organizational skills and attention to detail.

• Excellent verbal and written communication skills.

• Ability to maintain confidentiality and handle sensitive medical information appropriately.

• Proficiency in Microsoft Outlook, Word, Excel, and other applicable computer programs.

• Ability to manage multiple tasks, prioritize responsibilities, and work independently as well as part of a team.

• Previous clerical, medical records, or healthcare office experience is preferred.

What We Offer

Full-time employees are eligible for a competitive benefits package, including:

• Medical, dental, and vision insurance

• Paid vacation

• Paid time off (PTO)

• Holiday pay

• 403(b) retirement plan with employer-sponsored matching contributions

• Paid life insurance

Join Our Team!

At Chase Memorial Nursing Home and Rehab, your work helps support the team members who provide care to our residents every day. If you are dependable, organized, and ready to contribute to a positive healthcare environment, we encourage you to apply today!

Schedule: Full-time, Monday–Friday, 8:00 AM – 4:30 PM

Chase Memorial Nursing Home and Rehab – Good Shepherd Communities

Summary

It is our policy to comply with all applicable Federal and State laws prohibiting discrimination in employment based on actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex, or gender (including pregnancy, childbirth, and pregnancy-related conditions), gender identity or expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, genetic information, or any other characteristic protected by applicable federal, state or local laws and ordinances.

Notice to applicants: Good Shepherd Communities will reasonably accommodate an individual’s disability during both the application process and on the job. Please contact the Human Resources department to request any reasonable accommodation you may require to participate in the application process.