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

Jazz Pharmaceuticals

Neurology Account Manager - Pacific Northwest (Remote) Job at Jazz Pharmaceuticals

 ...passionate and experienced Neurology Account Manager who is committed to our mission of...  ...with internal and external partners:~ Customer Targeting & Sales Territory/Region/Area...  ...functional field leaders (Market Access, Patient Services, etc.) to achieve shared business... 

Perkins Restaurant & Bakery

Restaurant and Bakery Kitchen Manager Job at Perkins Restaurant & Bakery

 ...Perkins Restaurant & Bakery At Perkins Restaurant & Bakery our employees are part of the Perkins extended family and the families we serve. And you'll be responsible for making special days memorable and everyday meals something extraordinary. At Perkins where we've... 

Terra Contracting Inc

Heavy Equipment Mechanic Job at Terra Contracting Inc

 ...Job Overview Are you an experienced Heavy Equipment Mechanic with the skills to keep a hardworking fleet field-ready? Terra Contracting Inc. is searching for a skilled and proactive mechanic to join our team. In this vital role, you'll maintain, repair, and diagnose... 

BDJ Trucking Co

CDL-A Team OTR Truck Drivers Job at BDJ Trucking Co

 ...Description **$1000.00 Signing Bonus** The BDJ Commercial Team Driver will manage scheduled freight on a long-haul basis....  ...and retain fuel/toll receipts QUALIFICATIONS CDL-A License Tractor-trailer driving experience of at least... 

AAMCO Transmissions and Total Car Care

Automotive Technician Job at AAMCO Transmissions and Total Car Care

 ...We are seeking Automotive Technicians of all skill levels to join our growing team. The ideal candidates are detail-oriented, mechanically skilled, and passionate about diagnosing and repairing todays complex vehicles while delivering excellent customer service....