Clinical Document Specialist, Level I

NYC Health + Hospitals; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

Lincoln Medical and Mental Health Center, part of NYC Health + Hospitals, seeks a registered professional nurse to provide direct patient care across units, applying nursing methods, teaching, and care coordination.

Under supervision, maintains standards, documents care plans, collaborates with the health team, and participates in continuing education to advance professional practice.

Qualifications

• Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) or equivalent; BSN and four (4) years acute care experience.
• NYS license for Nurse Practitioner (NP) and two (2) years of experience as described in the RN path.
• NYS license for Physician Assistant (PA) and two (2) years of experience as described in the RN path.
• Foreign Medical Graduate with two (2) years of medical records review or utilization and case management experience.
• Completion of education leading to a medical degree with two (2) years of relevant experience.

Responsibilities

• Provides professional nursing care to patients/clients within an assigned unit.
• Diagnoses and treats responses to health problems by nursing methods and techniques.
• Develops, implements and evaluates the nursing regimen for patients/clients.
• Records and maintains nursing care plans and progress notes to ensure continuity of care.
• Interprets and reports patient responses to health team members and collaborates in planning a comprehensive care program.
• Guides and directs allied nursing personnel in nursing care delivery and evaluates nursing practices.

Education

NYS RN License + BSN + 4 years acute care experience

NYS Nurse Practitioner License + 2 years experience

NYS Physician Assistant License + 2 years experience

Foreign Medical Graduate + 2 years medical records review or utilization/case management

Graduate with medical degree + 2 years experience

Job description

Marketing Statement

Lincoln Medical and Mental Health Center is one of New York City’s premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women’s Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.

Mission

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Duties & Responsibilities

Purpose of Position

Under supervision, provides professional nursing care to patients/clients within an assigned unit. Diagnoses and treats responses to actual or potential health problems by means of nursing methods and techniques such as case-finding, health teaching, health counseling and provision of care supportive to and restorative of life and well-being.

Examples Of Typical Tasks

• Identifies and discriminates between physical and psycho-social signs and symptoms. Selects and performs those therapeutic measures which are essential for effective execution of the nursing regimen for assigned patients/clients.
• Develops, implements and continuously evaluates the nursing regimen for assigned patients/clients.
• Records and maintains nursing care plans and progress notes on patients/clients to ensure continuity of care.
• Interprets and reports responses of patients/clients to appropriate members of the health team.
• Participates with interdisciplinary health team members to plan a comprehensive patient care program.
• Determines and assigns those components of the nursing regimen which may be carried out by allied nursing personnel.
• Provides teaching, guidance and direction to allied nursing personnel in rendering patient care.
• Participates in defining, implementing, maintaining and interpreting standards of nursing practice.
• Participates in departmental and interdisciplinary conferences pertaining to policies and procedures affecting nursing practice.
• Participates in determining conditions, resources and policies essential to the delivery of nursing care services.
• Participates in development and maintenance of a system of evaluation of nursing care, practices and procedures, including evaluation of nursing personnel.
• Interprets philosophy and objectives of agency and Nursing Department to patients/clients, families and other groups.
• Maintains professional competence through participation in continuing education and other appropriate learning experiences.
• Performs other professional nursing activities as delegated by nursing service administration.

Minimum Qualifications

• Valid New York State license and current registration to practice as a Registered Professional Nurse(RN) issued by the New York State Education Department (NYSED); and Bachelor of Science inNursing degree from an accredited college or university; and four (4) years of acute care experience;or
• Valid New York State license and current registration to practice as a Nurse Practitioner (NP) issuedby the NYSED; and two (2) years of experience, as described in “1” above; or
• Valid New York State license and current registration to practice as a Physician Assistant (PA)issued by the NYSED; and two (2) years of experience, as described in “1” above; or
• Foreign Medical Graduate; and, two (2) years of medical records review or utilization and case management experience; or
• Successful completion of education that leads to a medical degree; and two (2) years of experience,as described in “4” above.