UNIT CLERK at Westchester Medical Center – Margaretville, New York

Job Summary

• 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 and/or Director HIM, to ensure that our medical records are maintained in an informative and descriptive manner.

Responsibilities

• Administrative Duties and Daily Functions
  • Completes work timely.
  • Follows all policies and procedures applicable to MRCC.
  • Creates and maintains an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unity and shift.
  • Cooperates with inter-departmental personnel.
  • Keeps working areas clean and clutter-free.
  • Maintains worksheets for nursing personnel for each unit.
  • Maintains files and resident medical records.
  • Assists medical staff with charge slips.
  • Maintains medical records accordingly.
  • Arranges transportation, sets-up appointments, access resident equipment, etc.
  • Notifies RN of any documentation discrepancies.
  • Maintains CPR/Code Blue information.
  • Assists in orienting new staff.
  • Adds information to the medical records as instructed.
  • Collects and reports data for the Quarterly QA Committee.
  • Provides secretarial functions for both units.
  • Assigns ICD-9-CM diagnosis codes to charge sheets.
  • Reviews admission, transfer or discharge paper work to determine diagnosis/symptoms necessitating transfer, or diagnosis appropriate to the admission or discharge.
• Communication:
  • Ensures appropriate and ongoing communication to staff, MD, IDT, etc.
  • Uses communication to enhance quality of resident care and staff working environment.
• Personnel/Staff Development
  • Attends mandatory inservices and meets minimum continuing education requirements.
  • Promotes a positive, friendly work environment.
• Quality Assurance:
  • Constantly strives to enhance the resident and staff experience.
  • Follows MRCC policies and procedures, including HIPAA.
  • Immediately reports unusual problem/accident/incident regarding resident care to RN/House Supervisor.
• Safety/Infection Control:
  • Is compliant with standards and regulations.
  • Reports potential outbreaks and takes appropriate measures to control/ eliminate infection control exposures.
• Other specific requirements:
  • Must have patience, tact, a cheerful disposition, and be enthusiastic.
  • Must work harmoniously with others.
  • Seeks out new methods and principles to incorporate into daily practices.
  • Creates and maintains an atmosphere of warmth, personal interest, positive emphasis, as well as a calm environment.
  • Promotes teamwork and collaboration among Mountainside staff members.
  • Is self-motivated.
• Ongoing education
  • Encouraged to pursue ongoing education.
• Other job duties as assigned.

Qualifications/Requirements

• EXPERIENCE
  • No experience required
• 
  EDUCATION
  • GED or High School Diploma