General Purpose

The primary purpose of your job position is to assist the Nurse Supervisor/Charge Nurse in their day-to-day recording and charting of medical or administrative information in accordance with current federal, state, and local standards, guidelines, and regulations that govern medical records, and as may be required by the Director of Nursing Services, to ensure that our medical records are maintained in an informative and descriptive manner.

Essential Duties

• Record medical and administrative information in accordance with our established charting and documentation policies and procedures

• Answer telephone, page calls, deliver messages to residents, etc., as necessary.

• Record appropriate resident identification data on designated medical records, wristbands, ID cards, etc., as required.

• Make appointments for patients and set up transportation

• Make Follow-up phone calls to request notes from appointments

• Scanning and uploading documents into patient charts

• Complete necessary medical and administrative records upon the resident's admission, transfer, and/or discharge.

• Forward completed charts of new admissions to the Medical Records/Health Information Department.

• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility.

• Greet newly admitted residents upon admission. Escort to room as necessary.

• Encourage attending physicians to record and sign progress notes, physicians' orders, etc., on a timely basis and in accordance with current regulations

• Attend and participate in annual facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.).

• Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids.

• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

• Treat all residents fairly, and with kindness, dignity, and respect.

• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.

• Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

• Other duties as assigned by the supervisor/DON/Administrator. Supervisory Requirements This position has no supervisor responsibilities

Qualification

Education and/or Experience

Must possess, as a minimum, a high school diploma or GED.

Must have exceptional communication and customer service skills.

Must be able to work in a fast pass environment.

Must have medical terminology knowledge

Front office experience making appointments and referrals.

Insurance knowledge a plus but not required.

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.

Ability to write reports, business correspondence, and procedure manuals.

Ability to effectively present information and respond to questions from managers and employees.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.

Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Certificates, Licenses, Registrations

To perform this job successfully, a basic knowledge of medical terminology and nursing practices is helpful

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee must occasionally lift and/or move up to 25 pounds. Prolonged use of a desktop or laptop computer. While performing the duties of this job, the employee is regularly required to sit, stand; walk and talk, read or hear. Frequent use of all office related equipment to include copier/scanner/fax, telephone, and calculator. May be necessary to assist in the evacuation of residents during emergency situations. Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually low to moderate.