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

Clayton County Public Schools

Lead Football Coach for K-12 Athletes Job at Clayton County Public Schools

 ...A public school district in Georgia seeks a Head Coach to oversee sports coaching for K-12 students. This role includes instructing students on sports fundamentals, managing team regulations, and coordinating practices. Candidates should have teaching certification or... 

Solvet

Pharmacy Tech Job at Solvet

 ...Description Job Description Solvet is searching for up to three Pharmacy Technicians to provide medication support services a federal...  ...equivalent Minimum 1 year of relevant experience (pharmacy tech, medical assistant, EMT, LVN, etc.) CPR certification (AHA or... 

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... 

Top Level Promotions

Work from Home Office Support Assistant Job at Top Level Promotions

 ...multiple industries. This entry-level position includes full training for qualified candidates. Depending on your skills and interests...  ...remote position ~ Flexible hours (part-time or full-time)~ Paid training included ~ Entry-level position with advancement... 

J.P. Morgan

VP Product, Digital Payments & Blockchain (San Francisco) Job at J.P. Morgan

 ...A leading financial institution is seeking a Product Manager for its blockchain initiatives. The successful candidate will develop innovative payment solutions, managing the end-to-end product life cycle. Applicants must have over 5 years in product management within...