Clinical Documentation Specialist Job at Norman Regional Health System, Norman, OK

V24vU3pXcjZPQi9RT2lVSXhKaXdGUnlyN0E9PQ==
  • Norman Regional Health System
  • Norman, OK

Job Description

Departmental Overview

Mission: To collaborate with providers, coders, and quality professionals to consistently document and capture the full clinical picture of each patient, leading to increased healthcare value, increased risk adjustment, and improved patient outcomes.

Vision: To be a national leader in provider documentation, setting the standard for excellence in accurate and compliant medical records that improve patient outcomes and operational efficiency.


Job Summary

  • Improves the overall quality and completeness of clinical documentation by performing systematic chart reviews on a daily basis, querying physicians and proactively soliciting clarification from physicians, as needed.
  • Demonstrates knowledge of documentation requirements and coding guidelines that pertain to diagnosis coding to accurately reflect the complexity and medical necessity of the encounter.
  • Routinely participates/provides education (including one-on-one education) to physicians, facility/clinic staff and other key healthcare providers.
  • Utilizes software systems to collect and ensure the effectiveness of the data.

Qualifications

Education

Associates Degree in Nursing required, Bachelors of Science in Nursing preferred.

Experience

3 to 5 years direct clinical nursing experience required

Experience in a broad range of clinical situations/settings preferred

Licensure/Certification

Current Oklahoma RN licensure required

Professional certification in Clinical Documentation, CCDS, CCDS-O or CDIP preferred and/or Professional coding certification, RHIA, RHIT, CCS, CCS-P, COC or CRC preferred

Other Knowledge/Skills/Abilities

Knowledge of Excel, Microsoft Word, Microsoft PowerPoint and Microsoft Outlook

Strong interpersonal, communication (verbal and non-verbal and listening) skills

Experience in developing and presenting education programs

Analytical skills

Needs to be self-motivated, self-directed and able to work independently with minimal supervision

Well organized and detail oriented

Capable of critical thinking, reasoning, deduction and inference while displaying the ability to draw accurate conclusions

If not already obtained, certification in Clinical Documentation and/or coding certification is voluntary but highly recommended within 3 - 5 years.

Work Shift

Day Norman Regional Health System

Job Tags

Shift work,

Similar Jobs

Private

Automotive General Sales Manager Job at Private

 ...AUTOMOTIVE GENERAL SALES MANAGER (GSM) Rare, $200,000+ a Year Opportunity! Automotive Sales Management Experience Required One of the areas top dealerships is looking for an outstanding GSM and leader who has a proven track record of achieving top... 

QPS Employment Group

Skilled - Welder Job at QPS Employment Group

 ...Position Title: Welder Wage: $30-$35/hour Shift: 1st Hours: 6am-2:30pm Were actively hiring skilled MIG Welders for a 1...  ...Friday) in OFallon, MO. Pay starts at $30$35 per hour, based on experience. Background check required. Work in an office and production... 

Ushers Machine and Tool Co., Inc.

Inventory Control Coordinator Job at Ushers Machine and Tool Co., Inc.

 ...Job Description Job Description Description: Inventory Control Coordinator Pelham Road in Greenville, SC | MondayFriday, 7:00 AM - 3:30 PM Join the power behind the turbines. Were a precision-driven manufacturing team supporting the industrial gas turbine... 

Tandym Group

Credentialed Alcoholism & Substance Abuse Counselor (CASAC) Job at Tandym Group

 ...Job Description A respected nonprofit organization in New York City is seeking a new CASAC Counselor to join one of their residential substance use treatment programs in Queens. In this role, the CASAC Counselor will be responsible for supporting individuals in recovery... 

LIVING THE DOG LIFE LLC

Pet Groomer Job at LIVING THE DOG LIFE LLC

 ...all work together to make sure our clients are happy and their pets look beautiful and are well-cared for while in our facility....  ...handling skills, along with strong knowledge and understanding in the grooming techniques of all breeds of dogs, experience is welcomed but not...