Registered Nurse

Registered Nurse (RN) – Clinical Documentation & Patient Intake We are seeking a dependable, detail-oriented Registered Nurse (RN) to join our clinical team in a Clinical Documentation & Patient Intake role. This position plays an important part in ensuring each patient encounter begins with accurate, thorough, and organized clinical information. The ideal candidate is an experienced RN who is comfortable speaking with patients, obtaining detailed medical histories, reviewing medications and previous treatment, taking vital signs, and accurately documenting information in the Electronic Health Record (EHR). Strong documentation, communication, organization, and computer skills are essential for this position. Work Hours: Tuesday, Wednesday, and/or Thursday 8am-430pm 630am-430pm once or twice per month on Tuesday Part-time position Will discuss individualized schedule on hire. Essential Duties & Responsibilities Greet patients and assist with efficient patient flow through the clinical area. Obtain and accurately document patient vital signs, including blood pressure, pulse, respirations, temperature, weight, and other measurements as required. Conduct detailed patient intake interviews and accurately document information in the EHR. Obtain and document a thorough History of Present Illness (HPI) , including current symptoms, pain complaints, onset, duration, severity, aggravating and alleviating factors, previous treatment, and response to treatment. Review and update past medical history, surgical history, social history, family history, allergies, and other pertinent clinical information. Perform and document an accurate Review of Systems (ROS) . Complete medication reconciliation at each applicable visit, including medication name, dosage, frequency, effectiveness, side effects, and changes since the previous visit. Review the patient's medical record prior to and during intake to identify information requiring clarification or updating. Document previous procedures, diagnostic testing, imaging, specialist care, hospitalizations, and other relevant treatment when applicable. Identify discrepancies or missing information in the medical record and obtain clarification from the patient when appropriate.Ensure clinical documentation is complete, accurate, organized, and ready for provider review. Prepare patient encounters within the EHR and ensure required documentation is entered in the appropriate sections of the medical record. Communicate pertinent patient concerns, changes in condition, abnormal vital signs, or other significant findings to the provider. Assist providers and other clinical staff with patient care and clinical workflow as needed. Respond appropriately to patient questions and communicate provider instructions within the scope of the LPN role. Assist with prescription refill requests, orders, forms, medical record requests, and other clinical documentation as assigned. Maintain accurate and timely documentation in accordance with organizational policies and applicable federal and state requirements. Maintain strict patient confidentiality and comply with HIPAA requirements at all times. Participate in chart review, documentation quality improvement, and clinical workflow initiatives as assigned. Maintain a professional, organized, and patient-centered clinical environment. Participate in medical literature research Review medical records and identify key elements Perform other clinical and administrative duties as assigned. Core Competencies Clinical Documentation – Demonstrates the ability to obtain detailed and relevant information from patients and translate that information into clear, accurate, and organized EHR documentation. Attention to Detail – Carefully reviews patient information and identifies inconsistencies, missing information, medication changes, and other details requiring clarification. Communication – Communicates professionally and effectively with patients, providers, coworkers, and other healthcare professionals. Uses effective questioning and listening skills to obtain complete patient information. Organization & Time Management – Effectively manages multiple patient encounters and responsibilities while maintaining accuracy and supporting efficient patient flow. Critical Thinking – Recognizes information that may be clinically significant and appropriately communicates concerns to the provider. Patient Service – Provides a professional, compassionate, and respectful patient experience while obtaining the detailed information necessary for the patient's visit. Teamwork – Works collaboratively with providers and clinical staff to support efficient workflow and high-quality patient care. Professional Requirements Maintain patient confidentiality and comply with HIPAA regulations at all times. Report to work on time and as scheduled. Maintain professional appearance and conduct. Complete required education, training, and regulatory requirements. Follow organizational policies, clinical procedures, infection-control standards, and applicable OSHA requirements. Demonstrate professionalism when interacting with patients, families, providers, coworkers, and outside organizations. Maintain accurate and timely clinical documentation. Participate in performance improvement and quality improvement activities as requested. Qualifications Graduate of an accredited nursing program. Current, unrestricted(RN) license required. Current BLS certification preferred/required based on position responsibilities. Previous experience in a physician office, outpatient clinic, specialty practice, or similar healthcare setting strongly preferred. Experience obtaining detailed patient histories and documenting within an EHR preferred. Previous pain management, neurology, orthopedics, primary care, or other specialty-clinic experience is a plus. Strong computer skills and previous EHR experience required. Ability to accurately document detailed clinical information while maintaining an efficient patient workflow. Skills Exceptional attention to detail and documentation accuracy. Strong patient interviewing and communication skills. Excellent written and verbal communication. Ability to ask appropriate follow-up questions to obtain a complete patient history. Strong computer and EHR proficiency. Ability to review and reconcile medications accurately. Strong organizational and time-management skills. Ability to work efficiently in a fast-paced clinical environment. Ability to prioritize responsibilities and communicate important findings to the provider. Professional, dependable, and team-oriented. Ideal Candidate The ideal candidate for this position is an RN who understands that thorough patient intake and accurate clinical documentation are essential to quality patient care . This individual should be comfortable asking detailed questions, reviewing complex medical histories, identifying missing or inconsistent information, and documenting clearly and efficiently in the EHR. Candidates who are highly organized, naturally detail-oriented, comfortable with technology, and skilled at communicating with patients will be especially well suited for this role. Part-time Benefits: Paid holidays and vacation #J-18808-Ljbffr Neuroscience and Pain Institute LLC