Unit Secretary

Position Title: Unit Secretary - CNA
FLSA Status: Non-Exempt

Job Summary:

The Unit Secretary - CNA provides a balance of administrative responsibilities and Certified Nursing Assistant (CNA) duties to maintain efficient unit operations and high-quality care for residents. This role involves managing medical records, ensuring regulatory compliance, and providing resident care as needed.

Duties and Responsibilities:

1. Administrative and Clerical Support (35%)
   • Answer intercoms, announce call lights, handle telephone communications, and screen personal calls.
   • Manage and maintain medical records, ensuring forms are filed, charts are updated, and Medication Administration Records and Treatment Sheets are properly stored.
   • Maintain a supply of forms and charts ready for new admissions, as well as ensuring an orderly nursing station environment.
   • Post updates for new residents on lists (e.g., bath, nursing summary, weight), complete notification and consultation forms (e.g., dietary, therapy, physician visits), and notify dietary department of resident absences.
   • Track routine lab work, physician visits, and therapy minutes for residents, particularly Medicare Part A residents, ensuring accurate records for services, certifications, and re-certifications.
   • Prepare and file lab requisitions, resident transfer forms, and therapy reports, ensuring compliance with facility procedures and physician directives.
2. Medical Record and Compliance Management (30%)
   • Maintain an organized filing system, adding medical record forms as needed and thinning medical records per the direction of the Medical Records Director.
   • Ensure records are prepared and accurate for Medicare Part A residents, maintaining lists of medication usage, therapy minutes, physician visits, lab work, and special equipment needs.
   • Track physician and Nurse Practitioner visits for regulatory compliance and ensure MDS assessments and care plan materials are properly documented.
   • Audit medical records to ensure completeness and accuracy, and assure all triple check items are signed by the appropriate physicians.
3. Resident Assistance (20%)
   • Participate in the Resident Feeding Program, assisting residents with meals per protocol.
   • Assist families with signing residents in and out using the Resident Leave of Absence book.
   • Support CNA duties when needed, including direct care, helping with daily living activities, and ensuring resident comfort and well-being.
4. Compliance and Training (10%)
   • Follow infection control guidelines and maintain privacy rules and regulations as per HIPAA.
   • Attend all meetings and complete in-services and mandatory training.
   • Provide exceptional customer service and high-quality care by showing compassion and empathy towards residents and their families.
5. Other Duties as Assigned (5%)

Qualifications:

• Education: High school graduate or equivalent.
• Certifications: Must maintain a valid South Carolina Certified Nursing Assistant (CNA) certification.
• Skills: Basic knowledge of medical terminology. Strong organizational skills, ability to manage medical records, and maintain regulatory compliance. Ability to effectively communicate with staff, residents, and families, while following established procedures.

Physical Requirements:

• Ability to lift up to 75 pounds and turn, move, and transport patients using proper body mechanics and lifting devices as needed.
• Capacity to stand, walk, and sit for extended periods.
• Ability to perform repetitive tasks and physical activities, such as bending, kneeling, and reaching.
• Work is performed in a healthcare setting with potential exposure to infectious diseases, bodily fluids, and chemicals.
• Must be able to work various shifts, including weekends, holidays, and overtime as needed.