Regency, A Villa Center -

JOB SUMMARY :

Under the supervision of the Unit Manager, the Ward Clerk / Unit Secretary implements facility policies and procedures to organize and maintain the medical record (health information) system in compliance with federal, state, and local requirements.

This position maintains a medical record system to meet the needs of the facility residents.

DUTIES / RESPONSIBILITIES :

• Assure that all medical record information is protected and kept confidential.
• Protect all medical record information from loss, defacing or destruction before retention period ends
• File medical records accurately.
• Retrieve medical records promptly upon request by authorized individuals and agencies.
• Identify late and incomplete documentation and report to individuals responsible for completion.
• Identify inaccurate documentation and report to individuals responsible for accuracy and documentation.
• Implement the system developed by the consultant for advising all disciplines of documentation to be completed or corrected.
• Mail forms to physicians, for completion, to the extent permitted by regulations.
• Maintain an accurate resident census report and distribute to designated individuals.
• Maintain a discharge analysis and disease index as required.
• Complete all information in master resident index file.
• Notify Administrator of all requests for information from medical records.
• Answer correspondence regarding release of information from medical records.
• Prepare records in answer to subpoenas.
• Assist the NHA and DON to coordinate all required committee and meeting functions.
• Record, type and file minutes for all committee meetings as assigned.
• Ensure Medicare residents have timely certification / re-certification forms signed by the attending physician.
• Enter data into the computer timely, accurately and completely.
• Print forms and reports from the computer program as required.
• Assist with quality assessment and assurance studies.
• Perform all duties assigned in an effective, timely and professional manner.
• Accept assigned duties in a cooperative manner.
• Assume accountability for all data contained in the employees’ handbook.
• Assume duties related to record review and data collection to verify Quality Indicators as assigned.
• Consistently work cooperatively with residents, residents’ representatives, facility staff, physicians, consultants, and ancillary service providers.
• Complies with laws and regulations applicable to position and acts in accordance with Villa’s Corporate Compliance Program.
• Follows facility dress and hygiene policies.
• Strictly follows policy and safeguards computer passwords and computer use authorities.
• Understands the importance of logging on and off the computer clinical ecord system and will consistently maintain all computer protocols.
• Ensure that all elements of the facility’s Abuse & Neglect policies are maintained and enforced.
• Safety
• Knows and follows facility rules.
• Demonstrates proper use of equipment. Reports equipment needs or repairs.
• Follows facility smoking policies.
• Reports and documents any incidents or accidents of residents, staff, or visitors to the
• Appropriate facility personnel.
• Reports all hazardous conditions / equipment to Supervisor.
• Performs duties, which may include transportation of residents, as assigned in Facility
• Disaster Plan.
• Uses required protective equipment.
• Follows infection control standards, policies and procedures.
• Resident Rights
• Knows Resident Rights. Help the residents / patients exercise and / or protect their rights.
• Reports resident / patient complaints to management.
• Maintains confidentiality of resident / patient information.
• HIPAA
• Follows and adheres to Villa’s policies and procedures implementing HIPAA
• Uses and / or discloses only minimum amount of Protected Health Information necessary
• to complete assigned tasks (applies only if position requires access to PHI under Role Based Access Grid).
• Reports all suspected violation of company’s HIPAA policies or procedures to Facility Privacy Designee.
• Performs other duties as needed.

REQUIRED SKILLS / ABILITIES :

• Ability to manage and supervise nursing staff.
• Ability to make independent decisions.
• Ability to relate positively, effectively, and appropriately with residents, families, community members, volunteers, and other facility staff.
• Demonstrates basic computer knowledge and ability with an aptitude to learn company applications.
• Detail-oriented.

EDUCATION and EXPERIENCE :

• High School Diploma or equivalent required.
• Degree in Medical Records preferred.
• One year of experience preferred.

ENVIRONMENTAL AND PHYSICAL REQUIREMENTS :

• Walking, reaching, bending, lifting, extended sitting, grasping, fine hand coordination, pushing and pulling, ability to distinguish smells and temperatures, all with or without the aid of mechanical devices is required.
• Limited potential for exposure to environmental hazards. Understanding and adherence to company safety standards and protocols required.
• Meet all health requirements as needed.
• Dialogue concerning ADA reasonable accommodations are always available upon request i.e. the interactive process.

B.E.T.T.E.R. is Villa's Service Excellence Code of Conduct. Becoming a member of the Villa Team includes upholding Villa’s B.

E.T.T.E.R. standards every day : Be Welcoming To All, Establish a Relationship, Trust & Respect, Teamwork, Engage & Communicate & Recognize.

This description has been prepared to assist individual VILLA Facilities in evaluating various classes of responsibilities, skills, and working conditions.

Facilities are independent Limited Liability Companies are free to amend or promulgate other guidelines. This job description indicates the kinds of tasks and levels of work difficulty required of positions given this classification.

It is not intended as a complete list of specific duties and responsibilities. Nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under supervision.

Nothing contained herein is intended or shall be construed to create or constitute a contract of employment or establish employment at will between any employee or group of employees and the facility.

The facility retains and reserves any and all rights to change, modify, amend, add to or delete from any section of this document as it deems, in its judgment, to be proper.

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Last updated : 2024-04-23