MEDICAL RECORDS / UNIT SECRETARY / FRONT DESK

PALMETTO CARE CENTER, A SKILLED NURSING FACILITY LOCATED IN HIALEAH, FL is seeking an experienced MEDICAL RECORDS /UNIT SECRETARY.  The primary purpose of your position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our Facility’s established privacy policies and procedures.

Previous medical records experience necessary.

 As the Medical Records/Unit Secretary/Front Desk you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Every effort has been made to identify the essential functions of this position.  However, it in no way states or implies that these are the only duties you will be required to perform.  The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is an essential function of the position. 

·         Receive and follow work schedule and instructions from your supervisor and as outlined in our established policies and procedures.

·         Assist in organizing, planning, and directing the medical records department in accordance with established policies and procedures.

·         Assist the Facility medical personnel, as required.

·         Develop and maintain a good working rapport with other departments within the Facility, to assure that medical records can be properly maintained.

·         Retrieve resident records (manually and electronically).  Deliver as necessary.

·         Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.

·         Collect, assemble, check and file resident charts, as required.

·         Ensure incomplete records and charts are returned to appropriate departments or personnel for correction.

·         Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.

·         Ensure all residents records are coded, stored, completed correctly, and maintained in a confidential manner.

·         Responsible for closure of discharged resident records.  Prepare record for closure by organizing the record in an orderly fashion, bind the record, and review record for completeness.  Works with nursing department for closure.

·         Tracks and monitors release of discharge resident records and thinned records to interdepartmental personnel and physicians.

·         Complete thinning or resident records in a timely manner to maintain appropriate forms on the record and delete those that are not needed on the active file.

·         Maintain thinned material from resident records in a neat and orderly manner.  Review thinned material for completeness.  Storage of thinned information in the station file cabinet on medical records in a neat and orderly fashion.

·         Ensure physician orders are signed within a timely fashion.

·         Maintain Credentialing and Privileging records for physicians.

·         Ensure Death Certificates are included in closed charts and notify nursing if missing.

·         Establish a procedure to ensure resident charts and records do not leave the medical records room except as authorized in our policies and procedures.

·         Maintain a record of authorized information released from charts and records, i.e., type information, name of recipient, date, department, etc.

·         Abstract information from records as authorized and required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.

·         Index medical records as directed by the medical records and health information consultant.

·         Maintain various registries as directed including register for admission and discharge of residents.

·         Assist the Quality Assessment and Assurance Coordinator in developing, implementing and maintaining an ongoing quality assurance program for medical records.

·         Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies.

·         Participate in QA/QI meetings on a monthly and/or quarterly basis.

·         Collect charts, assemble them in proper order, and inspect them for completion.

·         Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas, as necessary.

·         Must adhere to all HIPAA requirements.

Duties and Responsibilities of Unit Secretary

·                 Answer telephones and determine nature of call and direct caller to appropriate individual or department.

·        Receive and deliver messages or transfer calls to voice mail when appropriate personnel are unavailable.

·        Answer questions about the organization and provide callers with the address, directions, and other information.

·        Operate paging or telephone system, as required.

·        For residents without phones send calls to the nursing unit so they can facilitate communication with the resident.

·        Receive request from within the Facility and locate personnel through paging system.

·        Greet visitors and direct to appropriate office and/or resident room.

·        Provide directions and information to visitors, guests, residents, sales representatives, etc.

·        Offer beverages to visitors waiting for administrative personnel, as appropriate.

·        Ensure guests and visitors abide by existing rules, as directed.

·        Monitor visitor access and sign-in process.

·        Receive, sort, and distribute mail and maintain route publications.

·        Prepare and process correspondence for the Administrator and department directors, as necessary.

·        Order, receive, and maintain office supplies.

·        Perform other clerical duties such as filing, photocopying, and collating.

·        Provide administrative assistance to the Administrative staff. 

·        Assist with administrative duties as directed.  (Includes typing, filing, posting accounts, etc.)

·        Operate copier, office machines, etc., as directed.

·        Perform general secretarial and administrative duties as required or directed by the Administrator in support of the administrative functions of all departments within the Facility.

·        Accept and perform temporary or long-term assignments to various departments within the Facility, as required by the Administrator.

·        Maintain an adequate liaison with families and residents.

·        Maintain a productive working relationship with the medical profession and other health related facilities and organizations.

·        Maintain a current file and listing of residents by name and room number, emergency phone members of on-call personnel, department extensions, key personnel, etc.

·        Maintain a current listing of critical residents and/or residents who may not receive phone calls due to their condition.  (May refer such calls to Nurse Supervisor, LPN, or RN.)