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Form of workJOB SUMMARY To provide assistance with the timely and accurate completion of nursing documentation processes. Including but not limited to: Admission and re-admission documentation, medication reconciliation, review and collaborate on assessments, care plans and progress note documentation. The Clinical Support Nurse may work remotely, on-site or a combination of the two based on the results of their reviews. The Clinical Support Nurse shall collaborate with nurse consultants on the results of their reviews, and any patterns of adjustments that nurses needed to make based on policies, procedures and best practice. The Clinical Support Nurse shall provide comprehensive clinical advice to facility staff in a manner that promotes positive resident and patient outcomes.
QUALIFICATIONS A. Must possess a current, unencumbered License to practice as a Registered Nurse or Licensed Practical Nurse in the State of Illinois or Wisconsin. B. Minimum of an Associated Degree in Nursing. C. Previous clinical experience in Nursing. D. Must possess current CPR certificate or become certified within Ninety (90) days of employment. Certified CPR Instructor preferred. E. Must be able to read, write, and speak the English language in an understandable manner. F. Must possess leadership, abilities. Willingness to work harmoniously with all personnel remotely and in person. G. Must possess the ability to make independent decisions and to take directive action when circumstances warrant such action. H. Possess excellent communication abilities though listening, speaking, and writing skills.
JOB DESCRIPTION CLINICAL SUPPORT NURSE (cont'd) Page 2 III RESPONSIBILITIES A. Accepts and supports the Board of Directors philosophy of care, including the mission, standards and values. B. Consult with VP of Clinical Operations and the facility's Nurse Consultant in planning and implementing facility reviews. C. Attend and participate in relevant AMS Meetings (Teams/remote and/or in-person based on the nature of the meeting). D. Provide individual nurse specific in-service education as needed in the area of nursing documentation. Provide input to the nurse consultant and VP of Clinical Operations regarding the nursing educational needs.
JOB DUTIES A. Conducts and completes clinical documentation reviews and Support Nurses in the accurate completion of clinical documentation. B. Collaborates with appropriate personnel (nurses, CNAs, restorative aides, wound techs, and others), regarding the resident's status to determine the content needs of the clinical documentation. C. Responsible for collaborating with staff nurses, MDS coordinators, Restorative Nurses, DON and/or ADON to ensure the accurate completion of nursing documentation components on an ongoing basis, including but not limited to: 1. Admission/re-admission chart reviews 2. Medication reconciliation 3. Diagnosis coding review 4. Baseline care plan updates and personalization 5. Physician Notes review (new Diagnoses) 6. Physician signature calls to secure signatures 7. Risk Management (falls/incidents) documentation reviews 8. Dashboard clearing 9. POC compliance 10. Dietary recommendations carried out 11. Pharmacy recommendations carried out 12. Tracking surveillance antibiotic usage and resolving diagnoses for infections and updating care plans 13. Coordination of documents for scheduling appointments Effective 05-2022 D. Monitor facility regulatory compliance in areas of documentation. E. Identify and coordinate timely educational opportunities for nursing staff that would strengthen clinical documentation performance. F. Submit monthly reports to VP of Clinical Operations and VP of Operations. G. Assist other nurse consultants with chart reviews when needed. H. Assist with developing and monitoring corrective plans for documentation processes that are not compliant. I. Perform other related duties as assigned.
