30 Best clinical documentation improvement Jobs in Plainfield, New Jersey (May 2026)

Registered Nurse

14 days ago

Edison

When you join Sunrise Senior Living, you will be able to use your unique skills to empower residents to live longer, healthier, and happier lives. Not only will you build meaningful relationships with residents, their families, and team members alike, you will also gain joy in serving others and deep fulfillment in your work. Explore how you can follow your passions and shed light on meaningful ways to serve, grow, and shine together. Sunrise Senior Living was again certified as a Great Place to Work® by Activated Insights. This is the 8th time Sunrise has received this top culture and workplace designation, highlighting the special place Sunrise is to be a part of. COMMUNITY NAME Brighton Gardens of Edison Job ID 2026-239085 JOB OVERVIEW The Registered Nurse (RN) is responsible for providing direct guest/resident care and supervision and oversight of the guest/resident care by the licensed and non-licensed team members in the skilled nursing center. Responsible for leading and demonstrating the Mission for Sunrise Senior Living, "to champion the quality of life for all seniors" in accordance with federal, state and local standards and Sunrise Senior Living policies to promote the highest degree of quality care and services to our guests/residents. RESPONSIBILITIES & QUALIFICATIONS Essential Duties As a part of the Sunrise team, supporting our Mission, Principles of Service and Core Values is a fundamental part of this job. Our foundational belief is the sacred value of human life. The unique responsibilities for this role include but are not limited to the essential functions listed as follows: Clinical Care • Assists with the development and leadership of the Designated Nursing Assistants (DNA)/ Certified Nursing Assistants (C.N.A); follows Resident Centered Care model., • Assists with case management of both Medicare and non-Medicare guests/residents as needed., • Participates in the Care Planning meetings., • Assists with providing clinical care and not limited to: urinary cauterization, tube feedings, applying/changing dressings, Accu-checks, medication management/administration, admission, transfer and discharge of guests/residents., • Ensures interdisciplinary notes reflect the care provided through daily random audits., • Completes timely and accurate documentation of guests/residents charts., • Completes Incident Reports and reports to Director of Nursing Services (DNS)., • Reviews, updates and documents communication regarding residents to learn and share pertinent resident and community information., • Conducts effective visits/rounds at a minimum twice a day; conducts visits/rounds with physicians as necessary as assigned by DNS., • Research and documents all incidents of abuse, neglect and misappropriation of funds as assigned by DNS or Executive Director, Skilled Nursing Administrator., • Participates actively in the Clinical IDT Meetings and in the Daily Prospective Payment System (PPS) meetings to obtain information on admissions and discharges for the day / week., • Assists in monitoring medication records and administration., • Assists in receiving lab, x-ray and other test results and communicates appropriately.Quality Assurance, Regulatory Compliance, • Strives for excellent quality care and service delivery as measured in the 5 Star and Quality Measures process in demonstration and knowledge of standard practices and excellent resident care and services., • Demonstrates and knowledgeable in the following key quality improvement areas:, • Skilled nursing transformation and Resident Centered Care Model, • Sunrise and Federal Quality Indicator, • Demonstrates and knowledgeable in the following key regulations:, • All Federal, State/Provincial and Local resident care nursing regulations, • Resident Rights, • Resident Assessment Instrument process, • Participates actively in Federal, State/Province, Local surveys.Restorative, • Maintains knowledge of Restorative Practices of the Resident Assessment Instrument (RAI) process., • Leads and follows the documentation guidelines of the Restorative process, • Monitors the documentation for the Restorative program., • Monitors for resident decline /improvement in condition., • Refers resident/guests to restorative nursing as indicated.Clinical Systems, • Demonstrates Sunrise practices and guidelines for care and services surrounding guest/resident's skin, nutrition, behavior, falls, bowel/bladder., • Assists in implementation, training and monitoring of documentation related to clinical systems weekly, • Consults with physician as appropriate., • Ensures guest/resident changes, concerns and/or solutions to Director of Nursing Services as appropriate.Infection Control, • Understands and follows infection control practices., • Provides training as needed to support infection control practices., • Understands and practices the proper method of attending to and disposing of and the possibility of exposure to blood borne pathogens, bodily fluids, infectious waste, sharp sticks and hazardous materials in compliance with universal care precautions., • Reports occupational exposures to blood, body fluids, infectious materials, sharp sticks and hazardous chemicals immediately., • Ensures oxygen tanks are stored safely, exchanges guest/residents tanks when empty and monitors to make sure liters of oxygen are at prescribed levels.Medication Management, • Transcribes physician orders eMAR (Medication Administration Record / Treatment Administration Record) accurately and promptly to include initials, date and time 'noted' and date faxed to pharmacy., • Demonstrates and knowledgeable of the Six (6) Rights of Medication Pass ("Right" resident, medication, dosage, time, route, right to refuse)., • Maintains knowledge in the appropriate medication for appropriate diagnosis for the senior population., • Provides leadership and follows Sunrise and nursing standards for taking orders from physicians and administering medications., • Ensures current guest/resident photo with dates for all guest/resident on eMAR., • Completes eMar audit each month., • Monitors the Medication Room, med charts, treatment carts for neatness, cleanliness, availability of medications and expired medications.Guest/Resident, Family and Visitor Relations, • Responds to guest/resident and family, visitor's request in a timely and professional warm manner., • Communicates with families regarding the guest/resident medical care and seek new methods to incorporate guest/resident requests into existing nursing standards., • Coordinates and utilizes available health care resources., • Maintains confidentiality of all guest/resident information., • Reviews SCC dashboard 24 hour report, high priority progress notes.Risk Management and Safety, • Partners with community team to ensure community is in compliance with national/provincial regulations pertaining to occupational health and safety requirements and promotion of Risk Management programs and policies; adherence to safety rules and regulations., • Practices safety procedures at all times including Personal Protective Equipment (PPE), fire extinguishers, Safety Data Sheet (SDS) and Lockout Tagout procedures., • As applicable, all Sunrise team members who drive a Sunrise vehicle must sign the Driver job description and understand the key essential duties for safety and regulatory compliance.Training, and Contributing to Team Success, • Participates actively as a member of a team and committed to working toward team goals., • Demonstrates in daily interactions with others, our Team Member Credo., • Committed to serving our residents and guests through our Principles of Service., • Contributes in the overall engagement programs and processes (customer and team member engagement) including participating in the team member engagement survey and engagement improvement planning workshops., • Attends regular meetings; Town Hall, Department Team Meetings, Cross Over, and others as directed by the Supervisor / Department Coordinator., • Assists with supervising team members through hiring, orientation, training, performance evaluations and delegation of duties as assigned by the Director of Nursing Services., • Maintains compliance in assigned required training and all training required by state/province or other regulating authorities as applicable to this role to ensure that Sunrise standards are always met., • Performs other duties as assigned. Core Competencies • Building Customer Loyalty, • Building Trust, • Communication, • Contributing to Team Success, • Managing Work (includes Time Management), • Planning and Organizing, • Quality Orientation, • Stress Tolerance, • Technical / Professional Knowledge Experience and Qualifications • Graduate of approved college / school of nursing, • Maintains a current state/provincial license as a professional Registered Nurse (RN), • One (1) year supervisory and management experience in a skilled nursing, long term care, hospital or home health environment including hiring team members, coaching and discipline, performance management, daily operations supervision, • Demonstrated knowledge of nursing practices, techniques and methods applied to skilled nursing; federal and state/province long term care regulations, • Understanding of the Resident Assessment Instrument (RAI) and the Care Plan Process, • Ability to handle multiple priorities, • Ability to delegate assignments to the appropriate individuals based on their skills, roles and interests, • Possess written and verbal skills for effective communication and the ability to teach and guide clinical team members to provide quality care, • Competent in organizational, time management skills, • Demonstrates good judgment, problem solving and decision making skills, • Demonstration of proficiency in computer skills, Microsoft Office (Windows, Outlook, Excel) and Sunrise applications with the ability to learn new applications, • Ability to work weekends, evenings and flexible hours, available to our customers at peak service delivery days and times ABOUT SUNRISE Ready to take the next step and make a bigger impact than you ever imagined? As part of our team, you will help brighten the future for everyone at Sunrise and beyond. That is why we make it a priority to celebrate the unique ways you bring moments of togetherness and joy to everyone you serve. And when combined with the support, benefits, and growth opportunities we offer, the result is a career that PositivelyShines with everything you need to reach your goals - at work and in your life. We also offer benefits and other compensation that include: • Medical, Dental, Vision, Life, and Disability Plans, • Retirement Savings Plans, • Employee Assistant Program / Discount Program, • Paid time off (PTO), sick time, and holiday pay, • myFlexPay offered to get paid within hours of a shift, • Tuition Reimbursement, • In addition to base compensation, Sunrise may offer discretionary and/or non-discretionary bonuses. The eligibility to receive such a bonus will depend on the employee's position, plan/program offered by Sunrise at the time, and required performance pursuant to the plan/program. PRE-EMPLOYMENT REQUIREMENTS Sunrise considers the health and safety of its residents, family members, and team members among its highest priorities. Employment with Sunrise is contingent upon completing and passing a drug test (which does not include marijuana) and Tuberculosis Test, and a physical evaluation and a background check where required. Covid-19 and Influenza vaccination may be required if mandated by applicable federal, state, and local laws and authorities. COMPENSATION DISCLAIMER Selected candidates will be offered competitive compensation based on geographic location of community/office, skills, experience, qualifications, and certifications/licenses (where applicable).

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