Resident Care & Medical Records Clerk

Poway Healthcare Center; Poway (CA); Sur place; USD 42 000 - 61 000; Plein temps

Résumé du poste

Poway Healthcare Center is seeking a Medical Records Clerk to assist the Nurse Supervisor with recording and charting of medical and administrative information in compliance with current standards and regulations. You will maintain census data, resident rosters, and documentation accuracy across admissions, transfers, and discharges.

The role requires precise transcription, strong communication, and organizational skills, with duties including charting, audits, and coordinating with multiple

Qualifications

• Exceptional communication and customer service skills.
• Ability to read, analyze, and interpret general business materials.
• Ability to write reports, business correspondence, and procedures.
• Ability to present information clearly to managers and staff.
• Mathematical skills for fractions, percentages, and ratios.
• Ability to solve practical problems with varied instructions.

Responsabilités

• Record medical and administrative information per charting policies and procedures.
• Maintain the Daily Census Report and submit to the Nurse Supervisor/Charge Nurse.
• Maintain an up-to-date roster of residents for the assigned unit.
• Fill out resident charge slips and submit to the Business Office.
• Answer telephone, paging, and deliver messages to residents as needed.
• Maintain emergency contact listings for the unit.
• Forward daily tardy and absentee reports to the Business Office.
• Record resident identification data on medical records, wristbands, etc.
• Transcribe physicians' orders to care plans, medication cards, etc.
• Report transcription discrepancies to the Nurse Supervisor/Charge Nurse.
• Review medication cards for accuracy and legibility.
• Chart nurses' notes reflecting care provided and resident responses.
• Notify next-of-kin when a resident's condition changes.
• Admit, transfer, and discharge residents; assist with transportation and belongings.
• Complete medical and administrative records at admission/transfer/discharge.
• Forward completed charts to Health Information Department.
• Attend facility committee meetings as required.
• Assist in developing work assignments and schedules.
• Maintain good working rapport with inter-departmental staff.
• Inform nursing staff of new admissions and room assignments.
• Greet new admissions and escort to rooms as needed.
• Encourage physicians to record and sign progress notes and orders timely.
• Inform families of resident deaths as instructed.
• Call funeral homes when requested by family.
• Participate in annual in-service training programs (OSHA, HIPAA, etc.).
• Participate in training for procedures involving exposure to blood/body fluids.
• Assist with infection control program monitoring.
• Inform Nurse Supervisor of equipment and supply needs.
• Ensure staff refer to care plans before administering care.
• Report suspected fraud related to billing or cost reports, etc.
• Treat residents with fairness, kindness, dignity, and respect.
• Record all incidents/accidents as per policy.
• Do not disclose resident health information; report violations.

Connaissances

Communication

Customer service

Reading ability

Writing ability

Attention to detail

Formation

High school diploma or GED

Description du poste

Poway Healthcare Center is seeking a Medical Records Clerk to assist the Nurse Supervisor with recording and charting of medical and administrative information in compliance with current standards and regulations. You will maintain census data, resident rosters, and documentation accuracy across admissions, transfers, and discharges.

The role requires precise transcription, strong communication, and organizational skills, with duties including charting, audits, and coordinating with multiple