Clinical Documentation & Admissions Nurse RN

Clinical Documentation & Admissions Nurse (RN)

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