Professional Medical Coder Jobs in Springfield, IL

The Registered Nurse - High Acuity Urgent Care is responsible for professional nursing care according to individual needs of the patient population within the rules and Regulations of the Illinois Nurse Practice Act, managing the operation of the office on a daily basis, and functioning as an integral part of the patient care team to coordinate patient care by interacting with care team members, all Clinic departments, hospitals, nursing homes, and home care agencies.

Job Relationships

Reports to the Operations Manager

Principal Responsibilities

• Executes nursing intervention by collaborating with the inter-professional team incorporating appropriate standards of care for practice and patient outcomes.
• Evaluates patient's response to plan of care and works in collaboration with the inter-professional team to make any needed adjustments. 
• Interview for a nursing history, assessment of health knowledge and maintenance, and documents findings in the medical record.
• Obtain medical information, chief complaints, vital signs and diagnostic test results in preparation for physician examination and documents in the medical record.
• Serve as a patient advocate by protecting patient rights and gives attention to complaints regarding service.
• Evaluate the need for a referral to other agencies or providers such as Home Health or community agencies.
• Screen all patient problems either in person or by phone with the resolution being advice or referral to physician.
• Provide a planned education program related to prevention, health maintenance, specific disease or condition and documents results in the medical record.
• Gives home care instruction for procedures and medications.
• Provide pre and postoperative instruction for specific surgical and/or medical procedures.
• Assess and monitor the patient during all phases of surgical and/or medical procedures.
• Document patient education in the medical record.
• Administer respiratory therapeutic treatments and document according to policy.
• Administer irrigations such as foley catheter, enemas, ear wash, and document results in medical record.
• Collect specimens including cultures and provides coding.
• Apply and remove casts, provide patient instruction and documents in medical record.
• Perform procedures such as catheterization, suture removal dressing changes following Infection Control Policy and document results in medical record.
• Administer medications by all routes except chemotherapy (with the exception of RN with a Chemotherapy and Biotherapy certificate), or IV blood and blood products.
• Assist the physician in the examination, treatment of the patient by handing instruments, providing dressings, preparing equipment, etc. according to Infection Control Policy.
• Restock supplies and carts as indicated daily.
• Check crash cart, defibrillator and medications daily, see that all equipment is present and in working order.
• Discharge the patient per orders of the physician to a responsible person, following guidelines as written in the Policy and Procedure Manual.
• Orient new personnel to specialty.
• Provide emotional support and guidance to patients/family.
• Serve on the STAT Code Team, may direct the team and provide education to staff.
• Serve as resource to nursing personnel throughout the Clinic.
• May serve as a Health Care Assistant according to hospital policy.
• Coordinate the nursing care of the patient by interacting with all Clinic departments, hospitals, nursing homes and pharmacies.
• Demonstrate professionalism by adhering to performance standards including dress code.
• Insure confidentiality for patients and staff.
• Maintain knowledge by attending appropriate education programs, reading current journals and literature and documents for yearly evaluation.
• Perform pre-certifications/referrals for insurance companies as necessary.
• Schedule procedures/surgeries as necessary.
• Comply with the Springfield Clinic incident reporting policy and procedures.
• Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
• Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
• Perform other job duties as assigned.

Education/Experience

• Educated as registered nurse by attaining an ADN, diploma or B.S.N.
• Emergency Room or Urgent Care experience preferred.

Licenses/Certificates

• Currently licensed as a Registered Nurse in the State of Illinois.
• CPR certification per American Heart Association guidelines required. 
• ACLS certification per American Heart Association guidelines required.
• PALS certification per American Heart Association guidelines required.

Knowledge, Skills and Abilities

• Practices independent nursing consistent with the Illinois Nurse Practice Act.
• Assumes accountability and responsibility for own practice and that, which is delegated.
• Ability to serve on appropriate committees.
• Charge nurse responsibilities on a rotational basis.
• Must have the ability to control emotions and maintain composure under stress, using tact and good judgement.
• Must maintain professional behavior.
• Must be capable of stooping, bending and lifting.
• Must be able to stand and walk for long periods.

Working Environment

• Works in office setting during the hours the Clinic is available to patients/families.
• Sitting vs. standing averages to 50-50%.
• Occasional heavy lifting required.
• Conditions include exposure to blood, body fluids, tissue and contagious diseases and/or potentially hazardous materials.

PHI/Privacy Level

HIPAA1