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

Lubbock Christian University

News Anchor I Job at Lubbock Christian University

The News Anchorserves as the primary presenter of news stories and other content for all platforms in a manner that is clear, engaging...  ...required.Minimum five years experience in news reporting or anchoring. (More or less depending on market size.)Excellent news... 

DV Trading

Experienced Trader Job at DV Trading

 ...financial markets and hedging opportunities to commodity producers and users. Now, DV group affiliates include two broker dealers, a cryptocurrency market making firm, and a bourgeoning investment adviser. Overview: For this very specific role, DV Trading is actively... 

Okta

Senior Solutions Engineer, Okta (Enterprise NE) Job at Okta

Senior Solutions Engineer, Okta (Enterprise NE)Okta is the worlds identity company. We give everyone safe access to any technology, anywhere, on any device or app. Our flexible, neutral productsOkta Platform and Auth0 Platformprovide secure access, authentication,... 

Specialty Medical Staffing

Hospital Pharmacist - Part-Time Job at Specialty Medical Staffing

 ...Hospital Pharmacist - Part-Time Specialty Medical is currently hiringfor a pharmacist position in the Logan, OH area. This is a part-time role for a highly respected local hospital. If you are a highly competent pharmacist looking for a new position, we would like... 

Sunstates Security

Armed Security Officer PT Job at Sunstates Security

 ...Sunstates Security is currently hiring for a Part-time armed Security Officer to work in the Colorado Springs area. Additional coverage may be needed on occasion. The rate of pay is $25.00/hr, paid weekly. Requirements:Armed Security experience requi Security Officer,...