Medical Records Specialist Full Time

NYU Langone Health is a world-class, patient-centered, integrated academic medical center, known for its excellence in clinical care, research, and education. It comprises more than 200 locations throughout the New York area, including five inpatient locations, a children's hospital, three emergency rooms and a level 1 trauma center. Also part of NYU Langone Health is the Laura and Isaac Perlmutter Cancer Center, a National Cancer Institute designated comprehensive cancer center, and NYU Grossman School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. At NYU Langone Health, equity, diversity, and inclusion are fundamental values. We strive to be a place where our exceptionally talented faculty, staff, and students of all identities can thrive. We embrace diversity, inclusion, and individual skills, ideas, and knowledge. For more information, go to nyulangone.org , a nd interact with us on LinkedIn , Glassdoor , Indeed , __ Facebook , Twitter , YouTube and Instagram .

Position Summary :

We have an exciting opportunity to join our team as a Registered Nurse, ACC 21 PACU.

In this role, the successful candidate Carries out patient care responsibilities with emphasis on decision-making related to the steps inthe nursing process to include assessment, diagnosis, identification of expected outcomes, planning, implementation and evaluation. Provides competent, safe and compassionate care based on established NYUHC Patient Care and Nursing Standards. As a member of theinterdisciplinary healthcare team, formulates the initial plan of care with the provider (physicianor nurse practitioner) and collaborates with them to implement a comprehensive patient-centered plan of care to achieve expected outcomes; utilizes principles of assignment and delegation consistent with the NY State Nurse Practice Act.

Job Responsibilities :

• Analyzes unit level quality data and participates in improvement efforts to achieve organizational goals within the quality and safety performance improvement plan, (QSPIP) and outperform benchmarks in nurse sensitive quality indicators (Include unit based quality measures e.g. HAPU, CAUTI, CLABSI, Falls).
• Collects, assesses and documents patient healthcare data.
• Directs the patient / family and interdisciplinary team o identify a plan of care and outcomes that are realistic and measurable.
• Prioritize care based upon data collected. Documents assessment and reassessment in medical records.
• Directs the coordination of patient care in a safe, timely and appropriate manner. Applies and supports the escalation process.
• Considers needs and behaviors of specific patient age groups and cultural groups in all patient care activities. Documents interventions per hospital standard.
• Educates the patient / family regarding health status and established plan of care.
• Determines learning needs of the patient / family. Implements an educational plan.
• Collaborates with the interdisciplinary team to modify expected outcomes.
• Documents learning outcomes of patient / family; evaluates and revises education plan. (Include utilization of EHR education tools)
• Evaluates the patient's progress towards expected outcomes.
• Involves the patient / family and interdisciplinary team in the evaluation process.
• Recognizes changes in patient condition and responds to variations in patient's progress by modifing the interventions.
• Reports documents and evaluates the effectiveness of the intervention(s).
• Coordinates and directs unit activities to provide patient care in a healing, humane and caring environment.
• Analyzes achievement of and contributes to unit throughput efficiencies and metrics. (Include unit throughput measures e.g. DBN, door to triage, assign to occupy, first case starts, room turnover)
• Complies with unit based and organizations professional standards, New York State Nurse Practice Act and regulations of relevant outside agencies, e.g., NY State Department of Health, The Joint Commission, regulatory requirements etc.
• Organizes staff assignments to ensure appropriate delegation of activities.
• Demonstrates ability to differentiate those activities which are in scope of professional nursing practice, and those that may be delegated to ancillary staff.
• Complies with annual education and mandatory / regulatory requirements (Include learning transcript and supportive documentation).
• Serves as a support, resource and preceptor for nursing staff and students.
• Engages in self-assessment and peer review; utilizes resources to meet individual learning need and promote professional development in clinical practice.
• Adheres to patient care and nursing standards in care delivery, and uses clinical practice guidelines (CPG).
• Participates in standard development and practice evaluation.
• Contributes to and utilizes the unit practice council (UPC) structure to critically appraise and influence practice (Include supportive evidence)

Minimum Qualifications :

To qualify you must have a Current Registered Professional Nurse in New York, Bachelors degree in Nursing required, Basic Life Support Certification through the American Heart Association, Fluent written and spoken English language skills..

Required Licenses : Registered Nurse License-NYS, Basic Life Support Cert

Preferred Qualifications :

Membership in pertinent professional organizations preferred.

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.

NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.

If you wish to view NYU Langone Health's EEO policies, please click here. Please click here to view the Federal "EEO is the law" poster or visit for more information.

NYU Langone Health provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $106,600.00 - $131,350.00 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need. The salary range or contractual rate listed does not include bonuses / incentive, differential pay or other forms of compensation or benefits.

To view the Pay Transparency Notice, please click here

Required Skills

Required Experience