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

Noblesoft Solutions

Python Developer Job at Noblesoft Solutions

 ...development, programming, coding of Information Technology solutions using Python Responsible for documentation of the system, conduct unit tests, peer code reviews and maintenance of internally developed applications, evaluation and performance testing of purchased... 

Charles Schwab

Specialist, Brokerage Service Representative - 401k and HSA Job at Charles Schwab

 ...currently be authorized to work in the United States on a full-time basis without employer sponsorship. Personal Choice Investment Services (PCIS) Participant Services works directly with Self-Directed Brokerage Accounts for retirement plans and health savings accounts... 

Manpower

CNC Machinist- 3,4 and 5 Axis Job at Manpower

 ...Interested?Stop your job search and apply today! A recruiter will be in touch within 24 hours. Share this job with friends and family and earn dollars with every successful hire. ManpowerGroup recognizes the importance of providing an accessible and barrier-free... 

CoreCivic

Correctional Dental Assistant Job at CoreCivic

 ...Job Description CoreCivic is seeking a Correctional Dental Assistant for a job in Nicholls, Georgia. Job Description & Requirements Specialty: Dental Assistant Discipline: Allied Health Professional Duration: Ongoing Employment Type: Staff... 

Lallaks Delivery Service

Commercial Driver's License A/B Truck Driver Job at Lallaks Delivery Service

 ...Job Description Job Description We are seeking a skilled and reliable Truck Driver to join our team. The ideal candidate will have experience in various types of truck driving, including but not limited to tractor-trailer, flatbed, and refrigerated trailer operations...