Clinical Documentation Improvement Specialist (RN)

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

Benefits offered by this job

Employee Assistance Program

Health, Dental, and Vision Insurance

401K

Paid Time Off

Tuition Discounts

Pet Insurance

Job summary

A healthcare provider in New Mexico seeks a Clinical Documentation Improvement Specialist to oversee documentation for regulatory compliance and reimbursement in nursing facilities. Responsibilities include reviewing charts, collaborating with various departments, and educating staff. Candidates must be a graduate of an accredited nursing program with current RN licensure and a minimum of three years clinical experience, preferably in long-term care. The position offers competitive compensation and benefits.

Qualifications

• Minimum 3 years full-time clinical experience.
• At least 2 years in long-term care nursing, 1 year in management or supervisory role.
• Current BLS/CPR certification and RN license required.

Responsibilities

• Oversee clinical documentation for compliance and reimbursement.
• Review resident charts and ensure accuracy of documentation.
• Collaborate with interdisciplinary teams to gather information.
• Monitor changes in patient conditions and update documentation.
• Audit charts for missing information and ensure staff compliance.
• Educate staff on HNF documentation practices.

Skills

Clinical assessment

Clinical judgement

Documentation practices

Education

Graduate of accredited nursing school

Current RN licensure

BSN preferred

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.