via Indeed
$73K - 73K a year
Manage and maintain accurate medical records, perform patient assessments and procedures, support clinical workflows, conduct quality assurance audits, and collaborate with multidisciplinary teams in acute care settings.
Active RN license, experience with hospice care and medical record systems, strong communication skills, and ability to perform clinical procedures and documentation in person.
Experience is preferred. Hospice MD system in use. Medical record organize. Reviewing field nurses' notes. QA medical charts. Create orders&plan of cares. Good communication skills. Understanding Hospice Care. Active RN license. Remote Work is NOT allowed, please do not apply for remote work. HCH090419@gmail.com Email your Resume. Duties • Manage and maintain accurate and complete medical records in compliance with HIPAA and NCQA standards. • Perform patient assessments including vital signs, intake documentation, and physical examinations. • Assist with documentation of procedures such as suturing, IV insertion, catheter care, and medication administration. • Support clinical workflows involving laboratory specimen collection/processing, diagnostic evaluations, and specimen handling. • Ensure proper documentation of patient care activities including discharge planning, post-acute care coordination, and triage assessments. • Utilize EMR/EHR systems such as Epic, Cerner, Athenahealth, or eClinicalWorks for data entry and retrieval. • Conduct quality assurance audits related to medical records accuracy and compliance with accreditation standards. • Support infection control protocols and aseptic techniques during procedures like ostomy care or sterile processing. • Assist in managing complex cases involving trauma medicine, ICU care, hospice & palliative medicine, or behavioral health cases. • Collaborate with multidisciplinary teams in acute care environments such as Level I Trauma Centers or teaching hospitals. • Administer injections and perform phlebotomy as needed while adhering to sterile technique protocols. • Document patient assessments related to specialized areas including neurovascular status post-catheterization or ventilator management. Skills • Extensive experience with EMR/EHR systems including Epic, Cerner, Athenahealth, or eClinicalWorks. • Proficiency in medical coding (ICD-9/10), CPT coding, and medical documentation standards. • Strong knowledge of anatomy, physiology, pharmacology, and diagnostic evaluation procedures. • Ability to perform complex patient assessments including vital signs monitoring and physical examinations across diverse populations such as pediatrics or geriatrics. • Skilled in medication administration techniques including injections and IV infusion management. • Familiarity with infection control practices and aseptic techniques in sterile environments. • Excellent organizational skills for managing large volumes of medical records while ensuring compliance with HIPAA regulations. • Critical thinking skills necessary for triage assessments in urgent or emergency settings like urgent care or emergency rooms. • Experience working with patients with disabilities or developmental delays in settings such as assisted living or memory care facilities is advantageous. • Ability to coordinate discharge planning and post-discharge follow-up within outpatient or home & community care environments. • Strong communication skills for collaborating effectively within multidisciplinary teams across hospital medicine, outpatient clinics, or long-term care facilities. This position is integral to delivering exceptional patient-centered healthcare through meticulous recordkeeping and quality assurance practices while supporting clinical operations across various specialties. The successful candidate will demonstrate a comprehensive understanding of medical procedures combined with excellent organizational capabilities to uphold the highest standards of patient safety and regulatory compliance. Pay: From $35.00 per hour Expected hours: No more than 40.0 per week Benefits: • Paid time off Work Location: In person
This job posting was last updated on 12/9/2025