Clinical Documentation Improvement Specialist (RN)

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

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.