Unit Secretary / HIM Coordinator Full-time

Job description

Overview
Dual role: Unit Secretary (PCT experience) mixed with HIM Coordinator.
Monday-Friday 8AM-4:30PM.
The Unit Secretary / HIM Coordinator plays a vital dual role in supporting hospital unit operations and managing patient health records. Primarily serving as the primary clerical and receptionist anchor for the nursing unit, this position is responsible for day-to-day nursing station activities, patient chart upkeep, scanning, and routine record auditing. In addition, the position handles essential Health Information Management (HIM) coordination duties, including processing records for compliance, facilitating chart assembly/indexing
Primary Responsibilities: Unit Secretary Operations & Chart Upkeep
• Nursing Unit Reception & Clerical Support:
• Answer telephone and intercom systems, take accurate messages, and direct calls or

visitors to appropriate personnel.
• Perform clerical duties related to patient admissions, transfers/room changes, and

discharges.
• Order unit supplies and equipment; maintain an organized, clean physical environment

and stock clerical/charting areas.
• Assist patients, families, visitors, and clinical staff on the nursing unit as needed.
• Assist in orienting new staff to clerical duties and station procedures.
• Chart Upkeep & Order Processing:
• Compile new patient charts upon admission and maintain current, active charts on the

nursing unit.
• Pick up, deliver, assemble, and track physical and electronic patient charts across the unit

and hospital.
• Assist physicians and clinical personnel in retrieving patient data and medical records.

Secondary Responsibilities: Scanning, Record Auditing & HIM Coordination
• Scanning & Indexing:
• Scan and index patient documents—such as nurses’ notes, assessments, progress notes,

laboratory/x-ray reports, and correspondence—into the electronic medical record (EMR)
system according to hospital policy.
• Auditing & Record Compliance:
• Perform routine record audits to identify incomplete charts, missing signatures, or

coding/documentation gaps.
• Notify appropriate clinical departments and physicians regarding deficient or incomplete

records for timely resolution.
• Assist with the review of medical records for timely completion, data accuracy, and

regulatory compliance.
• HIM Coordination & Information Release:
• Ensure medical records removed from the department or unit are appropriately logged out

and tracked upon return.
STANDARD JOB DUTIES
• Demonstrates professional conduct and complies with hospital and departmental policies and procedures.
• Adheres to hospital attendance and safety policies.
• Limits access to Protected Health Information (PHI) to the minimum necessary to perform job responsibilities.
• Respects and demonstrates awareness of the rights, dignity, and individuality of each patient in all interactions.
• Performs other incidental and related duties as required or assigned.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
Education/Experience:
• At least an Associate’s Degree required (Degree in Health Information Management, Healthcare Administration, or related field preferred).
• Preferred 1 year secretarial experience, preferably in a medical office or healthcare environment.

Computer Skills:
Knowledge of basic computer skills, word processing, and Electronic Medical Record (EMR) system, preferably EPIC.
Certificates and Licenses:
Basic Life Support (BLS) Certification required.
Supervisory Responsibilities:
This job has no supervisory responsibilities.
Work Environment:
The work environment is representative of that which an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually moderate.
Physical Demands:
The physical demands of this job are representative of those that must be met by an employee to successfully perform the essential functions of the position. Reasonable accommodation may be made to a qualified individual with a disability who can perform the essential functions of this position with or without reasonable accommodation.
The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus while performing the duties of this job. The employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; talk; and hear.