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

Grow West

Driver (Class C) Job at Grow West

 ...Job Title: Delivery Driver (Class C) Division: All Reports To: Dispatcher FLSA Status: Non-Exempt Special Notes: This role will...  ...to obtaining the license. Summary: Drives a delivery truck including light duty, heavy duty, flat bed or tanker and delivers... 

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... 

Dexian

Python Developer Job at Dexian

 ...Job Description Job Summary: Dexian is seeking a Python Developer for an opportunity with a client located in Charlotte, NC....  ...thinking and an aptitude for solving problems with technology Experience of using design and architectural patterns Design and development... 

El Angel Market LLC

CDL Class a Truck Driver Job at El Angel Market LLC

 ...Job Description Job Description We are seeking a Truck Driver to join our team! You will be responsible for safely operating a Semi-...  ...Minimum of 1 year experience Commercial driver's license Class A Ability to handle physical workload Strong work ethic A... 

Pride Health

Billing Coordinator Job at Pride Health

 ...Job Description Job Title: Billing Coordinator Location: New York City, NY 10017 Contract Duration: 13 Weeks Shift: 5x8 hours...  ...Required Skills & Experience: Two to three (2-3) years of Medical billing experience required, including knowledge of Medicare,...