RN Jobs in New Mexico

RN CLINICAL DOCUMENT SPECIALIST

apartment UNM Hospital location_onAlbuquerque, NM

Sign-On Bonus Available Relocation Assistance Available Minimum Offer $ 30.60/hr. Maximum Offer $ 41.94/hr. Compensation Disclaimer Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations. Department: HIM Clinical Documentation FTE: 1.00 Full Time Shift: Days Position Summary: Responsible for concurrent review (during the patient stay) of appropriate and complete clinical documentation in the medical record to support services ordered and/or received, support primary diagnosis, secondary diagnoses, and co-morbidities to improve medical record physician documentation to appropriately support the severity of patient illness and resource consumption. Responsible for addressing and communicating appropriate documentation findings with physicians and other caregivers as necessary via written queries and/or verbal communication. Responsible for follow up to obtain accurate and complete documentation in the medical record during the hospitalization. Utilization of abstracting and data entry software tools to perform coding, abstracting and reporting functions. Provide training for providers on appropriate clinical documentation as indicated. Indirectly assures case mix index, DRG assignment and severity/mortality profiles are accurate. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment. Detailed responsibilities: * REVIEW - In collaboration with the physician, nurse, patient care coordinator, and certified coding specialist (CCS), identify and record principle diagnoses, secondary diagnoses, procedures, and assign a working MS-DRG * CONCURRENT REVIEW - Conduct initial concurrent review and ongoing re-reviews for all selected admissions to initiate the tracking process, document findings on the MS-DRG worksheets, and identify other key quality indicators as appropriate * PROBLEM SOLVING - Interpret clinical information in the medical record, evaluate medications, vital signs, surgical outcomes, etc. Identify potential diagnoses based on this information and communicate with physicians to obtain appropriate documentation that most accurately reflects patient severity of illness * ABSTRACTS - Utilize monitoring tools to track the progress of the Documentation Improvement Program and identified quality indicator tracking elements, interpret tracking information and reports findings to the Health Information Management, Quality Management, and Utilization Review/Case Management meetings as requested * COMMUNICATION - Communicate with physician to obtain/clarify specific principal diagnoses or comorbidities and complications; request clarification of existing documentation. Facilitate assertive, tactful communication when encountering resistance due to perception that information is adequately documented to achieve complete documentation per coding guidelines * COORDINATION - Coordinate and facilitate communication between Health Information Management, Utilization Review/Case management, Quality Management, physician leadership to acquire, interpret, and transmit accurate diagnostic and procedure documentation. Inform Coding management of potential and/or actual problems * PROCESS IMPROVEMENT - Identify baseline outcomes; develop process improvement plans; prioritize and implement process improvement action plans; monitor and follow up on * REPORTS - Assist in the communication and distribution of physician profiling reports provided in conjunction with the Clinical Documentation Improvement Program software * REPORT ANALYSIS - Through report analysis, review how documentation reflects severity of illness and report pertinent results to appropriate entities (e.g., physicians, committee, intra-departmental, etc.) Perform individual and group analysis of physicians and outcomes related to service line documentation issues * EDUCATION - Provide information and education necessary to physicians and ancillary staff not responding to “queries” for appropriate follow up and consequences thereof. Identify opportunities for physician education to improve medical record documentation for severity of illness on an ongoing basis. Identify opportunities for coder education to improve coding for severity of illness and morbidity * CONFIDENTIALITY - Maintain confidentiality of patient records, adhering to HIPAA guidelines * OTHER - Perform other duties as assigned * COMPLIANCE - Identify the need to clarify documentation in medical records and initiate communication with physician, nurse, or patient care coordinator by utilizing the appropriate “query” tools in order to capture the documentation in the medical record that accurately supports the patient’s severity of illness and risk of mortality Qualifications Related Education and Experience may be substituted for one another on a year for year basis. Education: Essential: * Program Graduate Nonessential: * Bachelor's Degree Education specialization: Essential: * Nationally Accredited Nursing Graduate Nonessential: * Nursing Experience: Essential: 1 year directly related experience Nonessential: Documentation improvement experience Credentials: Essential: * RN in NM or as allowed by reciprocal agreement by NM Nonessential: * Certified Coding Specialist * Certified Doc Improvement Prac/Spec (CDIP or CDIS) Physical Conditions: Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible. Working conditions: Essential: * Minor Hazard - physical risks, dirt, dust, fumes, noise * May work rotating shifts, holidays and weekends

RN

Psych

Part-time

RN PSYCH INPATIENT

apartment UNM Hospital location_onAlbuquerque, NM

Sign-On Bonus Available Relocation Assistance Available Receive 17% Weekday Nights, 26% Weekend Nights and 15% Weekend Day shift differentials Minimum Offer $ 36.84/hr. Maximum Offer $ 45.33/hr. Compensation Disclaimer Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations. Department: Behavioral Svcs at MATS Center FTE: 0.60 Part Time Shift: Days Position Summary: Provide professional nursing care for assigned patients in a mental health/psychiatric environment. Design nursing care plans and assist in the development of overall care plans for psychiatric patients, ensure administration of appropriate overall care in a manner conducive to recovery. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include pediatric, adolescent, adult and geriatric age groups. Detailed responsibilities: * PATIENT CARE - Interview, examine, and assess the health status of psychiatric patients with various cognitive, emotional, developmental, social, and behavioral disorders * PATIENT CARE - Observe patient behavior, activities, and mental status; perform triage and crisis intervention * PATIENT CARE - Write treatment plans; coordinate patient drug and procedure activities; administer medication and treatment; provide and coordinate nursing care of assigned patients; may facilitate group therapy and/or education sessions * PATIENT CARE - Chart and report observed symptoms, reactions, treatments, and changes in the patients' conditions; collect and document data and information; may perform computerized data entry * PATIENT CARE - Perform nursing intakes, draw blood and other patient specimens; may perform or coordinate laboratory tests * PATIENT CARE - Educate patients and families on treatment regimens, management of side effects, and compliance with the treatment plans; provide emotional support and acts as advocate for patients and families * PATIENT CARE - Provide information and facilitate communication between physicians, medical students, staff, patients, families, and community; coordinate and consult with a milieu of service providers * POLICY & PROCEDURE - Follow established departmental policies, procedures, and objectives, continuous quality improvement objectives, and safety, environmental, and/or infection control standards * DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops * ADMINISTRATION - Perform various administrative functions such as monitoring expenditures and preparing reports and correspondence; may participate in a variety of research projects to develop service plans; may propose changes to program policies and procedures * PRECEPTOR - Participate in orientation, and having successfully completed preceptor training, assume precepting and evaluation responsibilities of new personnel * TESTS AND PROCEDURES - Assist with special tests and procedures, ensure proper consent has been obtained * EMERGENCY MEASURES - Assist with or institute emergency measures for sudden, adverse developments in patients * MEDICATION - Administer medication, including IV medication, via the Seven Rights; document and communicate clinical findings * ENVIRONMENT - Maintain a safe, comfortable, and therapeutic environment for patients/families in accordance with Hospitals standards * PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols * PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes * PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk * PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner * PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may 'not seem right' Qualifications Education: Essential: * Program Graduate Nonessential: * Bachelor's Degree Education specialization: Essential: * Nationally Accredited Nursing Graduate Nonessential: * Nursing Experience: Essential: Nonessential: Bilingual English, Spanish, Keres, Tewa, Tiwa, Towa, Zuni, or Navajo 1 year directly related experience Credentials: Essential: * CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days * RN in NM or as allowed by reciprocal agreement by NM Physical Conditions: Heavy Work: Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly to move objects or people. Physical Demand requirements are in excess of those for Medium Work. Working conditions: Essential: * Sig Haz: Physical risk/injuries due to combative patients * Sig Hazard: Chemicals, Bio Hazardous Materials req PPE * Tuberculosis testing is completed upon hire and additionally as required