Clinical Documentation & Admissions Nurse RN

apartment Gold Crest Care Center location_onNY 10469, US

Clinical Documentation & Admissions Nurse (RN)
Full-Time | Monday–Friday, 8:00 AM–4:00 PM

Gold Crest Care Center is seeking a dedicated and detail-oriented Clinical Documentation & Admissions Nurse (RN) to support our 175-bed CMS 5-Star skilled nursing facility located in the Pelham Gardens area of the Bronx, NY. This role provides essential clinical, documentation, and admissions support to the nursing department and collaborates closely with Unit Managers, the MDS Coordinator, and the interdisciplinary team to ensure accuracy, compliance, and seamless resident transitions.

Responsibilities:

Assist with the completion, review, and maintenance of clinical documentation to ensure accuracy and compliance with regulatory and facility standards
Support the admissions process, including pre-admission screenings, initial assessments, documentation review, and coordination of required clinical information
Participate in the initiation and updating of individualized, person-centered care plans
Collaborate with the MDS department to ensure timely and accurate documentation needed for assessments
Assist Unit Managers with clinical follow-up, audits, and documentation as needed
Review physician orders for accuracy, ensure proper transcription, and follow up to confirm implementation
Provide clinical support to the nursing staff, helping reinforce adherence to nursing standards, policies, and regulatory requirements
Participate in daily morning meetings and communicate relevant updates to the interdisciplinary team
Assist in incident documentation and follow-up to ensure timely and complete reporting
Support infection control, quality assurance, and risk management activities through documentation review and coordination
Maintain strict confidentiality of resident information and ensure adherence to HIPAA standards
Foster a resident-centered environment through respectful communication, timely follow-up, and supportive collaboration with families and staff

Requirements:

Valid NYS Registered Nurse (RN) License
Prior experience in long-term care or skilled nursing required
Strong documentation skills and working knowledge of EMR systems

Competitive Salary & Comprehensive Benefits Package

Job Type: Full-time

Benefits:

401(k)
Dental insurance
Health insurance
Paid time off

Ability to Commute:

Bronx, NY 10469 (Preferred)

Work Location: In person

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