Job Description

Job Title:                        RN, HIE Document Management 

Reports To:                    Nursing Program Manager

Job Summary:                     Assists with the management and review of documents into the Electronic Health Record (EHR) associated with adult patients transition of care documents, Health Information Exchange (HIE) and specialist referral documents in collaboration with the Primary Care Provider.

                                                                                                                                                                       

 

Essential Job Duties and Responsibilities:

The requirements listed below are representative of the knowledge, skill, and/or ability required.  Job duties may be modified at any time based on business need.

 

  • Reviews all incoming Transition of Care/ Documents to include but not limited to ER/Hospital discharge notes and Specialists notes, received as Consolidated Clinical Document Architecture (CCDA’s) and reconciles medication lists and active diagnoses as appropriate
  • Notifies providers of new diagnoses or changes in medication regimens when appropriate
  • Maintains accurate, detailed reports and records.
  • Monitors, records and reports symptoms and changes in patients’ conditions.
  • Records patients’ medical information and vital signs when appropriate.
  • Consults and coordinates with Patient Care Team Members to assess, plan, implement and evaluate patient care plans.

 

Additional Job Duties:

  • Duties that fall within the broad scope of this classification may be assigned.
  • Asks specific questions per established policies, procedures, and protocols, providing validity and reliability to the disposition that will assist the patient to make an informed decision about their health care.
  • Notifies physician in a timely manner, as appropriate, regarding unusual or unexpected events/problems requiring direct physician consultation or intervention.

 

Minimum Qualifications - Education, Experience, Certificates & Licenses:

  • Degree from an accredited nursing program.
  • Current Unrestricted Arizona State Nursing RN license.
  • Cardiopulmonary Resuscitation (CPR) certification required.
  • Driver's License and Proof of Insurance may be required if requesting mileage reimbursement.
  • Valid Fingerprint Clearance Card.

 

Preferred Qualifications:

  • Experience in a clinical setting preferred.

 

Required Language Skills:

  • Ability to comprehend and compose instructions, correspondence, and communications in English in both oral and written format.
  • Bilingual in English and Spanish is preferred, but not required.
  • Ability to effectively present information in one-on-one and small group situations to patients, internal providers and staff and other agency staff working in cooperation with the organization.

 

Physical Requirements:

  • Ability to frequently exert enough force to move objects weighing up to 25 pounds.
  • Ability to continuously remain in a stationary position.
  • Ability to constantly move about inside the workplace to assist patients, operate office or medical equipment, etc.
  • Possesses hand-eye coordination and manual dexterity necessary to constantly operate computer, telephone, other office machinery, and medical equipment.
  • Possesses close visual acuity necessary to accurately record and view information on a computer monitor, handwritten and typed documents.
  • Ability to discern the nature of sounds at a normal spoken volume.
  • Possesses range of body motion and ability to exert enough force to lift and move adult and pediatric patients.

 

Other Required Knowledge, Skills, and Abilities:

  • Ability to perform medical math that may include the use of ratio/proportion, dosage calculation, metric and household equivalents, roman numerals, abbreviations, and general math including percentages, etc.
  • Ability to gather data in an organized fashion from varied sources.
  • Ability to perform a variety of assignments and make decisions requiring independent judgment.
  • Ability to resolve challenges and work under pressure.
  • Displays high level of critical thinking and problem-solving skills.
  • Knowledge of health plans and community health centers preferred.
  • Knowledge of HIPAA rules and regulations.
  • Computer literacy required.
  • Knowledge of Electronic Health Records preferred.
  • Displays effective communication skills with patients, clinic staff and providers.
  • Ability to prioritize and plan work activities, use time efficiently and develop realistic action plans.

 

Work Environment & Conditions:

  • Work environment is typical of an administrative office setting with no substantial exposure to adverse environmental conditions.
  • Work environment is occasionally typical of a health clinic setting with occasional exposure to communicable diseases, bodily fluids, and hazardous chemicals.
  • Work occasionally involves use of medical equipment with proximity to electrical current, and exposure to moving mechanical parts and some hazardous chemicals.
  • Work requires reliable transportation as position requires occasional travel and extended hours to include early mornings, evenings, and weekends.