Ward Clerk (Healthcare)

Job Title: Ward Clerk

Job Summary:
We are seeking a highly organized and detail-oriented Ward Clerk to provide essential administrative and clerical support in a healthcare setting. This role involves managing patient records, coordinating communication, and ensuring compliance with documentation policies to support nursing staff and enhance patient care. Medical Assistant required, CNA preferred.

SCHEDULE: Monday-Friday

Key Responsibilities:

Administrative & Documentation:

• Record medical and administrative information in accordance with established charting and documentation policies.
• Maintain and submit the Daily Census Report to the Nurse Supervisor/Charge Nurse.
• Keep an updated roster of residents for the assigned unit.
• Fill out and submit resident charge slips to the Business Office.
• Maintain and update a listing of emergency phone numbers for the unit.
• Record and maintain appropriate resident identification data (medical records, wristbands, ID cards, etc.).
• Transcribe physician orders to care plans, medication cards, and treatment plans as required.
• Report discrepancies in transcriptions, diet orders/changes, and charting to the Nurse Supervisor/Charge Nurse.

Resident & Family Communication:

• Answer telephone calls, page calls, and deliver messages to residents as needed.
• Notify the resident's next of kin regarding any changes in their condition, as instructed.
• Inform family members of a resident's passing and coordinate with funeral homes when requested.
• Greet and assist newly admitted residents, escorting them to their rooms as necessary.
• Assist with resident admissions, transfers, and discharges, including arranging transportation and packing personal belongings.

Record Management & Compliance:

• Complete necessary medical and administrative records upon resident admission, transfer, or discharge.
• Forward completed charts of discharged residents to the Medical Records/Health Information Department.
• Review medication cards for completeness, accuracy, and legibility.
• Forward new diet orders and/or diet changes to the Director of Food Services.
• Participate in infection control monitoring and ensure compliance with communicable disease policies.

Support for Nursing Staff:

• Assist in developing work assignments and schedules for the nursing team as required.
• Ensure nursing staff reference resident care plans before providing care.
• Encourage attending physicians to update progress notes and sign physician's orders in compliance with regulations.

Meetings & Training:

• Attend facility committee meetings (e.g., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment).
• Participate in in-service training programs, including OSHA, TB, HIPAA, Abuse Prevention, Safety, and Infection Control.
• Report suspected fraud, false billing, or other compliance violations.

Resident Care & Emergency Preparedness:

• Assist in emergency evacuations when necessary.
• Treat all residents with kindness, dignity, and respect.
• Report and document all incidents or accidents in compliance with facility policies.

Qualifications:

Education & Experience:

• Medical Assistant required (MA)
• CNA license preferred
• High school diploma or GED required.
• Prior experience in a healthcare setting or clerical role preferred.
• Basic knowledge of medical terminology and nursing practices is helpful.

Skills & Abilities:

• Strong communication and customer service skills.
• Ability to read, analyze, and interpret medical and business documents.
• Strong problem-solving skills and ability to handle various administrative tasks.
• Ability to maintain confidentiality and comply with HIPAA regulations.

Physical Requirements:

• Ability to occasionally lift and/or move up to 25 lbs.
• Frequent sitting, standing, walking, and use of office equipment (computer, fax, copier, phone, etc.).

Work Environment:

• Low to moderate noise level in an office/healthcare setting.
• May require occasional assistance in emergency situations.

Additional Information:

This job description is intended to outline the general nature and level of work performed. Management reserves the right to assign or reassign duties and responsibilities as needed.