Medical Secretary. Full Time.

Resident File Oversight

• →Maintain electronic and paper-based resident medical records.
• →Conduct daily reviews of the resident list to ensure accurate documentation.
• →Perform monthly audits of paper medical records to verify completeness and compliance with policies and regulations.
• →Ensure medical evaluations, admission forms, and interval paperwork meet corporate and state standards for timeliness, accuracy, and completeness.
• →Verify all new orders or order changes have been picked up correctly by the nursing staff by crosschecking the medication received from the pharmacy, matches the script, and the information on the eMAR.
• →Report any missing, incorrect, or overdue documents to the Director of Integrated Care.
• →Maintain Refusal of Medication Forms in both electronic and paper medical records when necessary.
• →Verify that current medication prescriptions are uploaded and documented correctly in resident files.
• →Notify the Director of Integrated Care of any documentation inconsistencies or discrepancies.
• →Ensure that self-medication assessments are examined and signed off by the Director of Integrated Care.

Administrative Duties:

• →Communicate with residents, families, and care teams to facilitate seamless care coordination.
• →Conduct error analyses, identifying recurring documentation mistakes and reporting findings to the Director of Integrated Services.
• →Utilize computer systems for data entry, information retrieval, and documentation
  management.
• →Transcribe audio recordings, handwritten notes, and typed documents into structured reports,
  forms, manuals, and records.
• →Proofread and edit documents to ensure accuracy and clarity.
• →Organize and maintain electronic and paper-based medical records, making photocopies and
  filing documents as needed.

Compliance & Quality Assurance:

• →Ensure compliance with corporate policies and state health department regulations.
• →Support quality assurance initiatives by participating in audits, documentation reviews, and
  process improvements.
• →Identify and report trends or recurring errors to the Director of Wellness and/or Executive
  Director.
• →Support additional administrative and quality-related initiatives as assigned by the Director of
  Integrated Care.
• →Participates in on-going in-service and training programs
• →Follows emergency procedures
• →Understands and fully complies with Inspīr safety practices and procedures

• Medical Secretary, Health Information Management, or related experience preferred.
• Strong knowledge of medical terminology, nursing procedures, and healthcare regulations.
• Experience in electronic health records (EHR) systems and medical documentation.
• Exceptional organizational skills and attention to detail.
• Strong written and verbal communication skills for interaction with residents, families, and healthcare providers.
• Proficiency in Microsoft Office (Word, Excel, Outlook) and healthcare database systems.
• Ability to analyze documentation trends, identify errors, and implement corrective actions.
• Experience working in assisted living, skilled nursing, or healthcare settings is preferred.

• Competitive wages
• Flexible shifts
• Growth opportunities
• Bonus & incentive programs
• Competitive Benefits Package: including medical, dental, vision, 401K match, company paid time-off, life insurance policy, insurance deductibles and voluntary Aflac insurance for our full-time employees.