This position is a full-time hourly Unit Secretary in a skilled nursing facility. It is for the day shift. The schedule is based on the needs of the nursing unit hours shift will consist of 7am -3pm or 8am-4pm or 9am-5pm Prior Experience as a medical unit secretary is required. ­­­­Basic medical terminology preferred, experience with Microsoft products required. This role m aintains medical records, assists in the coordination of physician services & scheduling, schedules appointments working with transportation, maintains supplies, and performs general office tasks in addition to clerical duties as assigned. ESSENTIAL JOB DUTIES AND RESPONSIBILITIES : Medical Records (Electronic/Hardcopy): + Reviews all information prior to placing into the chart to assure accuracy, timeliness and chart integrity. + Audits and monitors resident medical record for completeness and compliance. + Performs the clerical tasks for all admissions, transfers and/or discharges. + Scans necessary documentation and places appropriate documentation in the current medical record on admission. + Communicates Admission, Transfer Discharge via email in a timely fashion if applicable to designated facility of employment within community wellness partners. + Maintains Demographic binder with pertinent documents. + Schedules discharge appointments and closes discharge charts if applicable to designated facility of employment within community wellness partners. + Scans results of outside diagnostic testing and consults into EMR. + Maintains and monitors all Advanced Directive information in both the hard copy and Electronic records. + Maintains up to date resident roster for the nursing units based on daily census and any changes in resident status. + Monitors all resident documentation for signatures as required. + Obtains physician signatures if missing. + Brings clinical documents to the HIS office as needed. + Updates resident family contact information in the EMR as needed/directed. + Initiates and tracks all Release of Information requests for unit residents. + Maintains chart audits and monitoring as directed to assure compliance. + Maintains up to date Nursing assignment sheets including but not limited to narcotic sheets, weight logs, nourishment sheets, CNA assignment sheets and etc. as applicable to facility of employment within community wellness partners. PHYSICIAN SERVICES AND SCHEDULING: + Coordinates Physician visits - schedules and assures everything is prepared/printed for MD visits as needed. + Coordinates with Unit Manager/designee for obtaining Physician signatures as needed. + Files all signed medical record information in to the chart, and scans necessary documents into EMR. + Prepares documentation as designated for Optometrist, Podiatrist and Dentist as provided. + Transcribes orders into EMR (Electronic Medical Record) for residents to receive these ancillary services as scheduled/needed. + Unit Secretaries must be available on nursing unit during Physician visits to assist as requested. + Monitors Physician compliance – notifies Unit Manager / HIS Dept. of non-compliance of any provider. APPOINTMENTS and TRANSPORTATION: + Interfaces with Transportation office regarding outside appointments as needed. + Schedules outside appointments and transportation for the residents as needed. + May contact family to accompany them as needed/requested. + Assures prior authorization paperwork is completed when necessary for transportation. + Initiates and assures accurate timely paperwork for all appointments/transfers/referrals for consultant appointments is available when resident is leaving facility. + Scheduling for Medicaid enrollees transportation services must take in a timely manner. All Medicaid enrollees must have a yearly 2015 form completed for transportation services. Online Medicaid scheduling permits scheduling out to later dates as needed. Upon Medicaid scheduling difficulties contact the HIS Dept. for assistance. SUPPLIES: + Maintains inventory control related to unit supplies through the use of appropriate par levels. + Catalogues equipment and maintains monthly list of rental equipment, specialty equipment as needed. + Maintains Medicare Part B supplies and documentation of received orders. + Frequently checking expiration dates on supplies and restocking if expired. + Assures central supply receives stock medicine orders as needed to ensure stock medications are on hand. + Checks all items from central supply against invoice copy/stock request to ensure receipt of inventory and maintains invoice file. + Maintains organized nursing storage/stock utility room for each nursing unit. OFFICE TASKS: + Directs calls and takes messages appropriately in a professional manner. + Performs clerical functions of the nursing unit, including maintaining organization of the nursing station and maintaining resource books as needed. + Distributes newspapers in the morning to the residents on the unit(s) and coordinates with the delivers resident mail daily. + Coordinates with other departments regarding admissions/discharges and transfers for providing equipment/services. + Requests maintenance repairs as needed and tracks completion status. + Answers questions and provides direction and assistance to visitors while following PHI/HIPAA guidelines. + Assists with customer concerns/complaints and coordinates as needed with Administrative staff. + Prepare forms, lists, rosters, and reports as needed. ADDITIONAL DUTIES: + Completes in-services and attends meetings as required. + Provides unit secretary services on all units as needed and as assigned. + Performs other related duties or miscellaneous duties as directed. KNOWLEDGE, SKILLS, and ABILITIES: Education: High School graduate, Associate Degree or higher preferred. Knowledge in medical terminology. + Proficient in Microsoft Office products. + Ability to establish effective communication skills (oral and written) + Able to maintain confidential information. + Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times angry people + Must be able to speak and write the English language in an understandable manner. + Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies PERSONAL REQUIREMENTS: Appropriate attire as required by department dress code. Must be able to work independently. Complies with the code of conduct and proper badge identification. PHYSICAL REQUIREMENTS: Sits, stands, bends, lifts and moves intermittently during working hours. Subject to frequent interruptions. Must be able to move intermittently throughout the workday. Must be in good health; be able to cope with the mental and emotional stress of this position. Must possess sight/hearing senses or use prosthetics that will enable senses to function adequately so that the requirements of this position can be fully met. Must be able to lift, push, pull, and move a minimum of fifty (50) pounds. Must be able to assist in the evacuation of residents. HIPAA COMPLIANCE: Demonstrates knowledge of and adheres to Community Wellness Partners policies and HIPAA regulations governing the confidentiality and security of protected health information for both manual and electronic patient records, charts, information and other confidential information including (but not limited to) employee records, computer access codes and passwords.