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Admissions/Medical Records Nurse
2 months ago
Job Summary:
The Admissions/Medical Records Nurse (RN) is a key member of the nursing team at Trilogy Health Services, responsible for ensuring the smooth operation of the admission intake and medical records functions. This role requires strong organizational and communication skills, as well as the ability to work independently and as part of a team.
Key Responsibilities:
- Assist the Director of Health Services and Assistant Director of Health Services in planning, organizing, developing, and directing the admission intake and medical records functions.
- Verify census events in the Electronic Health Record and complete scanning and attaching of resident documentation in MatrixCare to ensure Medical Records are complete.
- Complete admission assessments for all new residents and review with primary nurse.
- Assist in event investigations per ED/DHS/ADHS guidance.
- Complete nursing admission assessments and baseline care planning for new residents.
- Initiate and oversee restorative programs to ensure provision of services as needed.
- Ensure appropriate daily skilled documentation is assigned and completed.
- Closes discharged resident events and complete open observations.
- Ensure discharge order is obtained and in medical record.
Requirements:
- Must possess, at a minimum, a Nursing Degree from an accredited college or university.
- Must have and maintain a current, valid state RN/LPN license.
- Current, valid CPR certification required.
- Wound Care Certification (WCC) and Infection Preventionist certification preferred.
About Trilogy Health Services:
Trilogy Health Services is a leading provider of long-term care services, committed to delivering high-quality care and services to our residents and their families. We are proud to be a Fortune Best Places to Work in Aging Services and a certified Great Place to Work.
