Clinical Documentation Improvement Specialist (RN)

Genesis Healthcare; 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

Employee Foundation

Health, Dental, Vision, Life Insurance

401K

Paid Time Off

Free 24/7 virtual health care

On-Demand Pay Program

Pet Insurance

Disability insurance

Hospital Indemnity

Personal Accident

Critical Illness

Cancer Coverage

Job summary

Genesis HealthCare is seeking a Full-Time, On-Site Clinical Documentation Improvement Specialist to support multiple centers. You will oversee clinical documentation for High Nursing Facility care, ensuring accuracy for resident care, compliance, and reimbursement.

Responsibilities include chart reviews, collaboration with care teams, monitoring condition changes, staff education, and acuity communication with managed care.

Qualifications

• Must be a graduate of an accredited school of nursing with current RN licensure.
• Minimum three years of full-time or equivalent clinical experience required.
• Two+ years in long-term care nursing; one year in management/administrative or supervisory capacity preferred.
• BSN preferred.

Responsibilities

• Review 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 information.
• Monitor changing conditions 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.
• Communicate acuity levels with Managed Care Organizations per state regulations.

Skills

RN license

Clinical documentation

BLS/CPR

Education

RN degree or diploma

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

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 24/7 virtual health care provided by licensed doctors for all Anthem medically-enrolled employees and their immediate family members
• *On-Demand Pay Program that allows for instant access to a portion of the money you’ve already earned

We also offer several voluntary insurances such as:

• *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.

Genesis HealthCare, Inc. and all affiliated entities (collectively “Genesis”) has a strong commitment to diversity that is fully supported and practiced by our officers and leadership team. Genesis provides equal employment opportunities to all employees and applicants for employment without regard to actual or perceived race, color, religion, gender, gender expression, gender identity, sex, sexual orientation, HIV status, national origin, age, disability, marital status, pregnancy, ancestry, citizenship, genetic information, amnesty, military status or status as protected veterans, or any other legally protected characteristic. Genesis is an Aff…