Clinical Documentation Specialist I — Patient Care

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

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.