Unit Secretary (Ward Clerk)

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. 

Job type: Full-time or part-time