Part Time Medical Coder Jobs in Lewiston, ME (NOW HIRING)

POSITION PURPOSE:

The Nurse is responsible for all Nursing related services for each patient and for linking patients to the physicians and to outside medical resources. The nurse participates in the Interdisciplinary Team Meetings when necessary to inform the clinical team about medical issues and is available for emergency medical situations. The nurse provides all services under the supervision of the Director of Nursing. The Nurse is responsible for providing medical & history screens, providing routine nursing care, and overseeing the medical and psychiatric management of the patient in coordination with the attending physician. The nurse is also a member of the Treatment Team and provides input into the development of the Master Treatment Plan.

POSITION REQUIREMENTS/QUALIFICATIONS

EDUCATION:

A minimum of a Graduated from a Community College with Practical Nurse Degree.

EXPERIENCE:

A minimum of 1-year experience in a chemical dependency/psychiatric setting, preferably in a detox unit and/or inpatient, partial hospitalization and/or outpatient setting required.

Must have two years of sobriety prior to hire, if recovering from a substance use disorder and participate in a self-help program.
Detoxification experience preferred for detox locations.
Current (five-years) of no felonies.

LICENSURE/CERTIFICATION:

• Licensed to practice nursing in the appropriate state maintains current licensure per state requirements.
• Maintains current CPR.

KNOWLEDGE AND TRAINING REQUIREDAT TIME OF HIRE:

• Knowledge of addictions and mental health complications.
• Knowledge and competency in problem solving, stress management, ethics and team building.
• Knowledge of alcohol and other drugs that includes:
• Alcohol and addictive drugs and their physical, emotional, intellectual, and spiritual impact on the individual.
• Alcohol and addictive drugs and their impact on the family.
• Ability to determine if a medical emergency exists and to take appropriate action, when necessary.
• Knowledge of emergency procedures used in case of alcohol and/or drug overdose.
• Knowledge of the stages of alcohol and other drug withdrawals and ability to take appropriate action at each stage.

Knowledge of Federal, State and Municipal laws and/or regulations that regulate the treatment of alcoholism and drug addiction, including:

• Confidentiality
• Patient Rights
• Professional Code of Ethics
• Discrimination
• Knowledge of airborne and blood borne pathogens (TB, HIV, AIDS, HB) and risk reduction methodologies and the use of universal precautions.
• Flexibility to adapt to schedule changes and assumption of responsibilities not delineated in the job description which are related to work as a member of an addiction treatment team

AGE SPECIFIC INDIVIDUALS SERVED/ RESPONSIBILITY:

Adults or Adolescents

SPECIFIC AREAS OF RESPONSIBILITY TO POSITION

1. Completes the following documentation within 24 hours of the patient's admission to the program
   1. Admission Note
   2. Nursing Assessment
   3. Pre-Screen Testing
   4. HRS Consent Form
   5. Patient Health Examination
   6. Criteria for Admission Form (if Detox admit).
2. Transcribe Physician's Orders and implement all Medical Protocols as ordered.
3. Administer medications and monitor the detoxification process.
4. Confer with and assist the Medical Doctor and the Psychiatrist.
5. Make appropriate referrals using referral forms.
6. Conduct Nursing Assessments and monitoring of detoxification patients.
7. Manage medication management; trains staff in medication dispensing.
8. Observe and assess patients for clinical signs and symptoms and follow prescribed courses of treatment.
9. Determine and implement specific detoxification protocols as designated by the Medical Director.
10. Attend and participates in all "in-service" functions.
11. Assist with emergency situations and make immediate referrals.
12. Provide documentation which reflects services for each patient in accordance with licensure standards.
13. Maintain required training & continuing education.
14. Meet with patients requesting to see the doctor to determine the urgency of their medical needs and expedite treatment as required.
15. Effectively communicates concerns about patient health to the Medical Director and follows up, as necessary.
16. Under the supervision of the Medical Director, assists in educating patients about health problems and medical care.
17. Facilitate medication education for new patients and for all other patients starting new medications.
18. Assist the treatment team in incorporating medical issues into treatment planning.
19. Take verbal orders from the Medical Director, document them in the patient's record and carries them out accurately and professionally.
20. Provide routine nursing care under the supervision of the Medical Director.
21. Participate in regular meetings with the Clinical Director to discuss specific patient problems.
22. Facilitate Medical Groups as directed by Clinical Director / Director of Nursing.
23. Participate in regular department meetings and staff meetings.
24. Maintain effective communication between outside medical services and the facility.
25. Participate in Performance Improvement, Utilization Review, Fire & Disaster Committees, and others as requested.
26. Maintain up-to-date training in CPR, First Aid, Infection Control, Fire Safety, and other areas mandated by organizational policies.
27. Conduct suicide screenings, glucometer waived testing, medication administration, pain screenings, and vitals per protocol.
28. Protect the privacy of all client information in accordance with GRNH, LLC's privacy policies, procedures, and practices, as required by federal and state law, and in accordance with general principle of professionalism as a healthcare provider. Failure to comply with the company's policies and procedures on client privacy may result in disciplinary action up to and including termination of employment.
29. May access protected health information (PHI) and other patent information only to the extent that it is necessary to complete your job duties. The incumbent may only share such information with those who have specific client information you have in your possession to complete their job responsibilities related to treatment, payment or other GRNH, LLC operations.
30. Expected to report, without the threat of retaliation, any concerns regarding GRNH, LLC's policies and procedures on client privacy and any observed practices in violation of the policy to their supervisor.
31. Performs other duties assigned.

Texas Only:

1. Ability to recognize signs of withdrawal
2. Client observation and monitoring skills/ procedures
3. Knowledge of pregnancy related complications
4. Knowledge of complications requiring transfers
5. Knowledge of appropriate interventions
6. Knowledge of frequently used medications including purpose, precautions, and side effects