Entry Level Rn Data Abstractor Jobs in Claremore, OK

Description
Shift: Monday-Friday 8am-5pm
Registered Nurses (RN) in the Residential Care Facility provide direct and indirect nursing care, health assessment, monitoring, and care coordination in a Residential Care Facility (RCF) setting. The RN exercises independent nursing judgment within the scope of RN licensure as defined by the Oklahoma Board of Nursing and ensures compliance with Oklahoma State
Department of Health (OSDH) Residential Care regulations, physician orders, and facility policies and procedures. The position reports to the Administrator and/or Director of Nursing and collaborates closely with direct care staff, case managers, providers, and interdisciplinary teams. Ensures resident safety, medication management, and continuity of care. All nursing duties are
performed in accordance with the Oklahoma Nurse Practice Act, applicable administrative rules, organizational policies, and within the individual nurse's scope of licensure.
EDUCATION AND EXPERIENCE:
1. Active and unrestricted Registered Nurse (RN) license in the state of Oklahoma.
2. Associate Degree in Nursing (ADN) required; BSN preferred.
3. Minimum one (1) year of nursing experience preferred.
4. Experience in residential care, assisted living, long-term care, behavioral health, or
community-based nursing strongly preferred.
5. Experience in medication management, care coordination, and interdisciplinary
collaboration strongly preferred.
6. Knowledge of Oklahoma Residential Care Facility regulations strongly preferred.
KNOWLEDGE AND SKILLS:
1. Knowledge of nursing practices applicable to residential care settings, including chronic condition management, medication administration, and health monitoring.
2. Ability to conduct comprehensive nursing assessments and identify changes in resident conditions.
3. Competency in medication administration, injections (if applicable), and emergency response within RN scope.
4. Ability to evaluate medication effectiveness, side effects, and resident response.
5. Strong clinical judgement and decision-making skills.
6. Proficiency with EMRs, MARs, documentation systems, electronic calendars, and reporting systems.
7. Strong communication skills for internal and external collaboration.
8. Knowledge of infection control standards, safety protocols, and emergency procedures.
9. Ability to verbally de-escalate residents as needed.
10. Strong ability to work with intra and inter departmental teams, as well as community partners and other stakeholders.
11. Demonstrated ability to provide person-centered, trauma-informed, and culturally responsive care.
12. Demonstrated adherence to professional standards, ethical practice, and licensure requirements.
13. Contributes positively to the work environment and promotes a healthy work culture.
JOB DUTIES AND RESPONSIBILITIES:
Nursing Care and Resident Safety
1. Perform comprehensive nursing assessments including evaluation of physical health, functional status, and changes in condition.
2. Evaluate medication effectiveness, side effects, and adherence; communicate findings to prescribing providers.
3. Administer medications and treatments in accordance with provider orders and approved protocols.
4. Monitor resident health status and initiate nursing interventions as indicated.
5. Conduct medication management, monitor effectiveness, and ensure resident safety.
6. Exercise independent nursing judgment, including assessment, evaluation, triage, prioritization of care, escalation to providers or emergency services, and clinical decision-making within RN scope.
7. Initiate emergency response procedures and coordinate care during medical emergencies.
8. Perform chart reviews and documentation in EMR and MAR systems.
9. Provide direct nursing care, including medication administration, monitoring, and coordination with providers.
10. Provide care coordination, including communication with guardians, residential facilities, and community partners.
11. Assist with resident de-escalation and behavioral support as needed.
12. Collaborate with inter and intra departmental teams as well as external partners and stakeholders for continuity of care.
Staff Training and Clinical Support
1. Provide clinical guidance and support to direct care staff.
2. Assist with training related to medication administration, health monitoring, and infection control.
3. Support adherence to clinical protocols, policies, and safety standards.
Operational and Data Management
1. Ensure accurate and timely documentation in EMR and MAR systems.
2. Review clinical data, identify trends, and recommend workflow or care improvements.
3. Maintain compliance with OSDH Residential Care regulations and other applicable requirements.
Collaboration & Professional Development
1. Work collaboratively with providers, nurses, direct care staff, and administrative staff in a manner that promotes a positive facility culture and resident-centered care.
2. Participate in interdisciplinary team meetings, care conferences, and planning meetings.
3. Maintain professional and ethical communication with residents, families, and partners.
4. Engage in ongoing professional development and required training.
5. Review clinical reports, identify trends, and provide recommendations for improved
resident care.
6. Collaborate with direct supervisor to identify opportunities for improved clinical workflows and documentation practices.
7. Ensure compliance with regulatory standards and facility policies.
Other Duties
1. Cover shifts or provide on-call nursing support as needed.
2. Participate in quality improvement initiatives and special projects.
3. Perform other duties as reasonably assigned.
4. Travel as assigned for resident care or training purposes.
5. Maintain clean and safe work areas.
6. Participate in meetings, quality improvement initiatives, and interdisciplinary case
reviews.
7. Regular and predictable attendance is an essential job requirement.
8. Meet "satisfactory" expectations at any job performance evaluation. Quality of work will be evaluated through training, skill, or special purpose. Must be competent and adequate.
9. Job duties and responsibilities may shift with business needs