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Medical Records Nurse
3 months ago
Make your application after reading the following skill and qualification requirements for this position.
At Challenge Unlimited, our vision is to become a national leader in providing employment services to people with disabilities that empower them to reach their full potential. We intentionally provide opportunities for individuals with disabilities which will assist them to live, work, and participate in the community.
Challenge Unlimited is driven by its core values: community, helpfulness, abilities, leadership, learning, ethics, innovation, growth, and effective outcomes. It is these values that have powered Challenge Unlimited to its success and has helped over 600 disabled individuals find meaningful work across all of our locations.
Reporting to the Director of Nursing, the Nurse is responsible for providing nursing services to up to 48 Residents with developmental disabilities or mental illness living in group homes which provide opportunities for them to live in a home-based environment—achieving the highest level of independence possible.
Coordinates medical services and supplies with medical providers. Reviews and maintains medical documentation and audits health records and services documented by staff for compliance. The Nurse trains staff, provides vaccinations/injections, conducts tb screening for staff/residents and documents health services. The Nurse also provides on-call services during the assigned rotation schedule.
Shift: Full-Time, 8:00am - 4:30pm + rotating on-call every 12 weeks with evenings/weekends included.
89 per hour
Resident Relations: Promote a culture of person-centered services that advances the Company’s mission to provide quality care and services in a community-based setting to individuals with disabilities. Ensure a high rate of resident satisfaction. Ensure the health and safety needs of all residents are met by providing nursing services to residents. Participate in the screenings and interviews of prospective Residents as requested. Attend all Resident PP/ITP/IHP staffing meetings or send medical summary prior to the meeting.
Provide Nursing Services and Oversee the Health and Safety Needs of Residents: Plan, organize, and supervise the delivery of care to residential residents. Complete annual nursing assessment, quarterly nursing assessment, TD, self-medication assessment and monthly observations, admission, NSP’s, TB signs and symptoms check list, ensure annual influenza immunization and other immunizations are up to date, tetanus, pneumococcal, and hepatitis series. Visit assigned Residents no less than bi-weekly to evaluate their current condition and assist in healthcare planning. Communicate effectively with physicians & service providers regarding Resident care. Order medical supplies as needed.
Maintain and Review Documentation, Audit for Compliance: Maintain records of assigned Residents for medication charts, vaccinations, and annual assessments accurately and timely. Review all Physician Order Sheets and Medication Administration Records prior to being placed in the Resident’s chart in a timely manner (at least monthly). Ensure that each facility meets state, federal, CARF (Commission on Accreditation of Rehabilitation Facilities) and any governing agency’s regulatory guidelines.
On-Call Services: Provide on-call services to assigned group homes from 3pm to 7am Monday through Friday and scheduled weekends/evenings. Follows through with reported problems and communicates them to supervisor/primary care nurse. Check nurses’ mailbox at group homes weekly.
General Administrative Support: Train direct care staff on Basic Health and Safety, Medication Administration (if Nurse Trainer certified), and other health related topics as required per the Director of Nursing. Provide immunizations and TB testing to employees and maintain accurate records of the same.
Experience working with people with developmental disabilities or mental illness helpful, but not required.
CPR, Crisis Prevention Institute (CPI) and DSP (Direct Support Professional) training, including medication administration, provided by the company must be successfully completed within the first 4 months to be certified. Passing CPR and CPI training is also required annually.
Computer Skills: Proficient with Microsoft Word, Excel, and Outlook
Driving: Use of personal insured vehicle for Company related travel is required.
Must pass driving history check and Company policy criteria, maintain valid driver’s license and be 21 or older to drive for Company related local travel.
