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2 Clinical Documentation Specialist jobs match your search criteria.

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Job Description: TITLE Nurse Practitioner/Physician Assistant - Nights  REQ NUMBER MED-17-00011   DESCRIPTION St. Mary's Hospital for Children, located in Bayside, is currently seeking a qualified Nurse Practitioner or Physician Assistant to join their team of professionals! This qualified team player will deliver quality primary and sub-acute care to pediatric patients ranging in age from newborn to adolescence. This includes ordering medications, therapies, tests, and other procedures according to, but not limited to, mutually agreed upon practice protocols which are determined in collaboration between Nurse Practitioner/Physician Assistant and attending Physician. Responsible for monitoring responses to interventions and coordinating care utilizing all members of the interdisciplinary team. Plays a central role in communicating with family members and outside agencies to provide comprehensive care and discharge planning. This is a full time position 6 shifts (8pm-8am) in a two week pay period. This position will also rotate weekend and holidays with team members. JOB DUTIES / RESPONSIBILITIES 1. Performs all aspects of resident care which includes ongoing physical exams; ordering of appropriate diagnostic studies, consultations by subspecialists, treatments and medications; reevaluating responses to treatments; and records all encounters and pertinent clinical information in the Electronic Medical Record as progress notes or Medical Monthly Progress Notes. All responsibilities are in accordance with scope of practice and in collaboration with the supervising physicians. 2. Upon admission, performs and documents a complete history and physical assessment for assigned residents within 24hours and have reviewed and cosigned by physician. Initiates a realistic and appropriate treatment plan and coordinates care accordingly. 3. Communicates with staff/families regarding changes in resident condition and with other providers via accurate and timely signout. 4. Prescribes immunizations, as needed, according to the American Academy of Pediatrics guidelines. Monitors immunizations records of all inpatients to be in compliance with AAP and NYS guidelines. Notifies families according to hospital policies of upcoming immunizations. 5. Serves as a clinical resource for nursing staff/resident/family. Aids in educations of fellows, residents, medical students, along with other medical providers. 6. Facilitates coordination of care between St. Mary's Hospital for Children, outside agencies, and tertiary care facilities. Documents all such communication in the resident medical record. 7. Participates in facility’s Quality Improvement Program as well as Performance Improvement Projects 8. Shares gaps in hospital coverage in house with other medical providers. Aids and assists with in house coverage during disasters/emergencies/storms/PTO schedules. 9. Participates in departmental meetings, rounds, lectures, and educational activities in person or via conference call when possible. 10. Completes all mandated hospital compliance training in timely fashion. 11. Follows all required infection control, safety, and confidentiality guidelines/mandates. 12. Trained to complete the death certificate utilizing the NYC Electronic Death Registry System (EDRS) and completes such certificate in a timely fashion in event of a death. 13. Takes on clinical tasks as deemed appropriate by Medical Director. If you are looking for a work environment with a team of professionals who strives to improve the lives of its residents and patients every day, then we want to meet you! WHAT WE CAN OFFER YOU! Full-time employment with great developmental and growth opportunities A mission driven culture, committed to our values and kindness, that truly cares about our teammates and residents, and the communities we serve. New competitive salary and generous benefits. Learn more about St. Mary's Healthcare System for Children at www.stmaryskids.org where big hearts help little patients. St. Mary’s Healthcare System for Children is an Equal Opportunity Employer M/F/D/V/SO     FULL-TIME/PART-TIME Full-Time   SHIFT Nights   POSITION REQUIREMENTS Formal education required: Licensed in New York State as a Pediatric or Family Nurse Practitioner; or Licensed in New York State as a Physician Assistant. NYS Registration, PALS, ACLS, BLS certifications.   Previous experience required: Minimum of one year experience required in pediatrics for Nurse Practitioner Minimum of three years experience as a Nurse Practitioner preferred   EXEMPT/NON-EXEMPT Exempt   ABOUT THE ORGANIZATION St. Mary's is a national leader in intensive rehabilitation, specialized care and education for children with special needs and life-limiting conditions. St. Mary's is the largest post-acute care provider of its kind in New York State, with a continuum of care that supports the child throughout his/her lifetime from inpatient facility to home and community settings. Following hospitalizations for injury, illness or complications of premature birth or when special services are needed, children and their families come to St. Mary's to receive exceptional care, learn to manage their condition and achieve a better quality of life. St. Mary's touches the lives of thousands of children and their families through our inpatient, home care and community-based programs. We provide care in all five boroughs of New York City as well as through Nassau, Suffolk and Westchester counties. St. Mary's Hospital for Children, our inpatient facility in Bayside, Queens is New York City's only rehabilitation hospital for children. Our home care and community programs are based in Bayside, New Hyde Park and Roslyn caring for 2,000 children. St. Mary's is where big hearts help little patients.   EOE STATEMENT St. Mary's Healthcare System for Children is an Equal Employment Opportunity Employer M/F/D/V/SO   LOCATION St. Mary's Hospital for Children  

Job Description: Director of Quality Assurance   The Director of Quality Assurance is responsible for reviewing clinical documentation for established quality standards and overseeing the chart audit process. He or she is responsible for reviewing ICD-10 coding of admissions and OASIS management. The Director of QA works directly with QA RNs and also with clinical field staff by mentoring and working with RN Case Managers for utilization of services, case conferences and other clinical questions. Occasional supervisory field visits are required. The Director of QA is also responsible for assisting in the hiring, orientation and development of new RN Case Managers/QA RNs. Responsible as a member of the interdisciplinary and clinical management teams to the Executive Director for the provision of services information and related liaison/admit activity, implementation, delivery, coordination and supervision of home health and hospice services delivered to patients in their homes or facilities, respective team members, consistent with hospice policies and procedures. Manages, promotes, and coordinates the compliance and regulatory requirements of the QAPI committee process. Qualifications: The qualifications are: 1) Registered Nurse with a current license to practice in the state of PA; 2) Minimum of two years of QA-RN experience in a home care setting; 3) Baccalaureate or Master’s degree in nursing or a diploma from an accredited school or nursing; 4) HCS-D (Home Care Coding Specialist – Diagnosis) certified preferred. 5) 5 years clinical Registered Nurse experience; 6) 2-3 years’ experience in homecare including palliative care preferred; 7) Knowledge of Medicare State and Federal home health regulations; 8) Experience with OASIS-C1; 8) Proven ability to provide clinical leadership with multi-disciplinary teams. KeystoneCare is a Medicare Certified, CHAP Accredited, DPW licensed, independent home care and hospice agency. Our community focused, not-for-profit agency provides comprehensive nursing and rehabilitative services to chronically and terminally ill patients in their homes and in our 20-bed residential hospice facility located in Wyndmoor, PA. We offer an attractive compensation and benefits package and a 403b Retirement Savings Plan. KeystoneCare is an Equal Opportunity Employer and Drug-Free Workplace Job Type: Full-time

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If you’re a nurse who is tired of the long shifts and crazy hours, becoming a clinical documentation specialist may be the perfect career move for you.

Clinical documentation specialists are registered nurses who examine medical records to ensure that all information is correct, including diagnoses. However, they are more than proof-readers. Clinical documentation specialists look for patterns within health records and use that information to come up with solutions to healthcare issues.  

To qualify for clinical documentation specialist jobs, you must have 2-5 years of experience as a registered nurse. You should have excellent communication and organizational skills, and possess the ability to multitask. You must also be familiar with medical coding and stay in compliance of all legal regulations.

If you’re ready to take a detour from the traditional nursing career path, visit ADVANCE Healthcare Jobs today! You’ll find open clinical documentation specialist jobs across the country. If you want to stay local, you can easily customize the search to your area. Whatever your needs, ADVANCE Healthcare Jobs can help you find the right clinical documentation specialist positions for you.