RN Clinical Documentation Lead – Long-Term Care

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

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.