Unit Ward Clerk

Integritus Healthcare; South Yarmouth (MA); On-site; USD 30,000 - 33,000; Full time

Job summary

Windsor Skilled Nursing in South Yarmouth, MA seeks a Medical Records Clerk for Integritus Healthcare. The role supports organizing and maintaining resident charts, ensuring accuracy, privacy, and timely access for authorized personnel.

Qualifications include a high school diploma and a current CNA license in Massachusetts, with strong English skills and attention to detail. This is an on-site facility position offering benefits and opportunities for growth.

Qualifications

• High school diploma or equivalent.
• Knowledge of medical terminology.
• Current, unencumbered CNA license in this state.
• Read/write/speak/understand English.
• Ability to make independent decisions when needed.
• Ability to deal tactfully with residents, families, staff and the public.
• Ability to plan, organize, develop, implement & interpret programs and policies.
• Patience, tact, cheerful disposition and enthusiasm.

Responsibilities

• Organize, plan & direct the medical records section per policies.
• Maintain rapport with other departments to ensure proper records.
• Record incidents/accidents and file per policies.
• Collect, assemble, check, and file resident charts and records.
• Ensure incomplete records are corrected by nursing service.
• Develop procedures to ensure records are completed, signed, indexed, etc.
• Ensure charts do not leave the department except as policy allows.
• Maintain records of information taken from charts/records.
• Abstract information from records for insurers/Medicare/Medicaid/VA.
• Maintain registries including admission and discharge.
• Collect and organize charts; inspect for completion.
• Assist with miscellaneous duties for records and business office staff.
• Assist in admission, transfer and discharge procedures.
• Answer telephone inquiries; prepare written correspondence.
• Retrieve medical records for authorized personnel.
• Ensure proper checkout/sign-out of records.
• Index medical records as directed.
• Other duties as needed.

Skills

Medical terminology

English proficiency

Independent decision making

Interpersonal skills

Education

High school diploma or equivalent

Job description

Windsor Skilled Nursing
South Yarmouth, MA 02664, USA

• Pay or shift range: $22 USD to $24 USDThe estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons.

Description

Windsor has been part of the community since 1975, providing families with skilled nursing care for short-term rehabilitation and long-term care. We focus on maximizing patient recovery, comfort, and independence to support quality of life. Our experienced team offers compassionate, specialized care to reduce hospital readmissions and improve outcomes through rehab, long-term care, adult day health, and restorative services.

Be part of a collaborative, caring team at Integritus Healthcare. We offer excellent benefits, including generous paid time off and exceptional health insurance - plus real opportunities to grow your career. If you're ready to make a difference, we'd love to have you on board!

Essential Job Functions:

• Assist in organizing, planning & directing the medical records section in accordance with established policies and procedures.
• Maintain a working rapport with other departments in the facility to assure that medical records can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Collect, assemble, check, and file resident charts and personnel records as required.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
• Maintain records of information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
• Maintain various registries as directed including register for admission and discharge of residents.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
• Assist in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies, etc.)
• Assure that medical records taken from the department are signed out and signed in upon return to the department.
• File active and inactive records in accordance with established policies.
• Index medical records as directed.
• Other duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.

Qualifications:

• Must possess, as a minimum, a high school diploma or equivalent.
• Must have knowledge of medical terminology
• Must possess a current, unencumbered, active CNA license in this state.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must possess the ability to plan, organize, develop, implement, & interpret programs, goals, objectives, policies & procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.

Physical Requirements and Working Conditions: Will meet all physical requirements of the position as identified by the facility policies and procedures related to functional job analysis.

Other Duties: Please note this job description is not designed to cover or contain comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.