Clinical Documentation Improvement Specialist (RN)

Genesis Administrative Services LLC; Albuquerque (NM); On-site; USD 46,838 - 61,992; Full time

Benefits offered by this job

Health, Dental, Vision insurance

401K

Paid Time Off

Employee Assistance Program

Tuition Discounts

Free virtual health care

On-Demand Pay Program

Pet Insurance

Disability Insurance

Job summary

A healthcare services provider is seeking a Clinical Documentation Improvement Specialist, responsible for ensuring accuracy in clinical documentation and compliance with state guidelines. The role requires a registered nurse with at least three years of clinical experience, including two years in long-term care. Benefits include health insurance, tuition discounts, and various compensation plans. Competitive salary of $34.00 - $45.00 per hour is offered.

Qualifications

• Graduate of an accredited nursing school with current RN license.
• Minimum of three years of clinical experience required, with two years in long-term care nursing.
• Current BLS/CPR certification is mandatory.

Responsibilities

• Oversee clinical documentation for resident care and regulatory compliance.
• Review and ensure accuracy of required quality documentation.
• Collaborate with various staff to gather needed information.

Skills

Clinical assessment

Judgement skills

Education

Registered Nurse Licensure

Bachelor of Science in Nursing (BSN)

Job description

Overview

Genesis Healthcare is currently looking for a Clinical Documentation Improvement Specialist to join our team. You would support multiple centers in this role!

Responsibilities

The HNF Documentation Nurse is responsible for overseeing clinical documentation, completing, updating, and ensuring accuracy of all High Nursing Facility Level (HNF) and related clinical documentation required for resident care, regulatory compliance, and reimbursement. We are looking for someone with strong clinical assessment and judgement skills.

• Review resident charts, assessments, and care plans to complete required quality HNF documentation according to state guidelines based off of individual level of care
• Ensure all forms are accurate, timely, and compliant with state and facility standards
• Collaborate with nursing staff, therapy, social services, business office and providers to gather needed information
• Monitor changes in condition and update documentation accordingly
• Audit charts for missing or inconsistent information and follow up with staff
• Educate staff on proper documentation practices related to HNF requirements
• Effectively communicate and challenge appropriate acuity level(s) with Managed Care Organizations according to state regulations

Qualifications

Must be a graduate of an accredited school of nursing, college or university with a current registered nurse licensure by the State Board of Nursing.

A minimum of three years full-time or equivalent clinical experience is required and a minimum of two years of clinical experience in long-term care nursing with one year in a management/administrative or supervisory capacity is preferred. BSN preferred.

Must maintain current BLS/CPR certification and RN license.

Benefits

• Variable compensation plans
• Tuition, Travel, and Wireless Service Discounts
• Employee Assistance Program to support mental health
• Employee Foundation to financially assist through unforeseen hardships
• Health, Dental, Vision, Company-paid life insurance, 401K, Paid Time Off
• Free 24/7virtual health careprovided by licensed doctorsforall Anthemmedically-enrolled employees and theirimmediate family members
• On-Demand Pay Program that allows for instant access to a portion of the money you’ve already earned
• Pet Insurance
• Term and Whole Life Insurance
• Short-term Disability
• Hospital Indemnity
• Personal Accident
• Critical Illness
• Cancer Coverage

Restrictions apply based on collective bargaining agreements, applicable state law and factors such as pay classification, job grade, location, and length of service.

Posted Salary Range

USD $34.00 - USD $45.00 /Hr.