Clinical Documentation Improvement Specialist (RN)

Casa Real; Santa Fe (NM); On-site; USD 47,000 - 62,000; Full time

Benefits offered by this job

Variable compensation plans

Tuition, Travel, and Wireless Service

Employee Assistance Program

Health, Dental, Vision

401K

Paid Time Off

On-Demand Pay

Pet Insurance

Job summary

Casa Real in Santa Fe, NM is seeking a Full-Time, On-Site Clinical Documentation Improvement Specialist to support multiple centers. You will review resident charts, ensure accurate, timely HNF documentation, and collaborate with nursing, therapy, and providers to gather needed information.

The ideal candidate is a registered nurse with BSN preferred, holds current BLS/CPR, and brings several years of long-term care experience; salary ranges from $34 to $45 per hour with comprehensive benefits

Qualifications

• Must be a graduate of an accredited school of nursing with current RN licensure in the state.
• Minimum three years of full-time clinical experience required; two years in long-term care preferred with some supervisory exposure.

Responsibilities

• Review resident charts, assessments and care plans to complete required HNF documentation.
• Ensure forms are accurate, timely and compliant with state and facility standards.
• Collaborate with nursing, therapy, social services, business office and providers to gather needed information.
• Educate staff on proper documentation practices related to HNF requirements.
• Challenge acuity level determinations with Managed Care Organizations as per state regulations.

Skills

RN License

BLS/CPR

Long-term care

Education

BSN preferred

Job description

Overview

We are currently looking for a Full-Time, On-Site Clinical Documentation Improvement Specialist to join our team. You would support multiple centers in this role! We are dedicated to improving the lives we touch through the delivery of high-quality care and exceptional service. As a leading provider in the long-term care industry, we believe in fostering a collaborative, inclusive and supportive work environment where every team member is valued and empowered to make a difference. Whether you're an experienced professional or just starting your career, we offer opportunities for growth, development, and advancement in a range of roles. Join us in our mission to enhance the well-being of our patients and residents while making a meaningful impact in the communities we serve.

Responsibilities

• 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.