Unit Clerk

Company Overview
St. Barnabas Health System, Inc. is a leading healthcare provider committed to delivering compassionate, comprehensive care across multiple communities. With a rich history of service, our organization emphasizes patient-centered support and community engagement, ensuring quality healthcare for all individuals regardless of their financial circumstances.

Position Summary

The Unit Clerk provides clerical and administrative support to the nursing unit to ensure efficient operations and continuity of resident care. Responsibilities include maintaining medical records, transcribing physician orders, coordinating appointments and transportation, and facilitating communication between departments, providers, residents, and families. This role is critical to maintaining regulatory compliance, accurate documentation, and survey readiness. Must have current CNA certification.

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Objective of Position

To assist the Nursing Supervisor and interdisciplinary team with medical records, physician orders, appointment coordination, transportation logistics, and overall unit operations while ensuring compliance with facility policies, CMS requirements, and PA Department of Health regulations.

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Essential Duties and Responsibilities

Administrative & Clerical Functions

· Maintain and organize resident medical records (electronic and paper)

· Complete required documentation for admissions, transfers, and discharges

· Enter and update resident data in PointClickCare (PCC) or designated EMR

· Transcribe physician orders to charts, EMR, MAR/TAR, and care plans accurately and timely

· Maintain census reports, logs, and unit documentation

· Forward completed charts of discharged residents to Medical Records

· Record resident identification and required data on charts

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Appointments, Diagnostics & Transportation

· Schedule and confirm appointments (physicians, labs, x-rays, specialty consults)

· Arrange transportation (ambulance, wheelchair van, family transport)

· Ensure all required paperwork accompanies residents to appointments

· Track completion of appointments and communicate results to nursing staff

· Coordinate diagnostic and therapeutic services per physician orders

· Assist with requisitions and outside service coordination

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Admissions, Transfers & Discharges

· Assist with admission, transfer, and discharge processes

· Prepare and complete required record-keeping forms

· Coordinate transportation, packing, and documentation for transfers/discharges

· Ensure proper chart completion and forwarding to Medical Records

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Communication & Coordination

· Serve as liaison between nursing staff, physicians, departments, residents, and families

· Answer telephones and respond to inquiries per policy

· Dispatch messages to appropriate personnel and departments

· Maintain updated emergency contact lists at nursing stations

· Report discrepancies in physician orders, diet orders, or charting to supervisor

· Provide written and oral reports to nursing leadership as needed

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Medical Record & Clinical Support

· Assist in maintaining accurate, complete, and up-to-date medical records

· Chart vital signs (TPRs, blood pressure) as directed

· Forward diet orders and changes to Dietary Department

· Track clinical items (e.g., catheters, colostomy, tube feedings) for required documentation (CMNs)

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Unit Operations & Supply Management

· Maintain adequate stock of office and nursing unit supplies and forms

· Order supplies and ensure proper storage of equipment

· Keep nursing station clean, organized, and survey-ready

· Deliver mail, flowers, and items to residents as needed

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Environment, Safety & Culture

· Maintain a positive, calm, and resident-centered environment

· Develop and maintain effective working relationships with all departments

· Ensure unit area is safe, clean, and functional

· Report hazardous conditions or equipment issues immediately

· Maintain strict confidentiality of resident information (HIPAA compliance)

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Quality, Compliance & Training

· Follow all facility policies and procedures

· Support survey readiness and documentation compliance

· Assist in standardizing processes and workflows

· Participate in orientation and training of new unit clerks as assigned

· Assume responsibility and accountability for assigned duties

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Performance Expectations

· Accurate and timely use of PointClickCare (PCC) for documentation and order transcription

· Strong computer proficiency with minimal documentation errors

· Timely scheduling and coordination of appointments and transportation

· Organized, audit-ready, and compliant medical records

· Effective communication with interdisciplinary team

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Qualifications

Education

· High School Diploma or equivalent required

Experience

· Prior healthcare or skilled nursing experience is a must as is CNA certification.

· Experience with PointClickCare (PCC) or similar EMR strongly preferred

Required Skills & Competencies

· Must possess strong computer skills, including EMR systems, data entry, and Microsoft Office

· Working knowledge of PointClickCare (PCC) required or ability to demonstrate competency upon hire

- CNA

· Basic understanding of medical terminology

· Strong organizational and multitasking skills

· Excellent communication and interpersonal abilities

· High attention to detail and accuracy

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Physical & Mental Requirements

· Ability to sit, stand, and walk for extended periods

EOE

EOE

Salary : $24 - $25