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

The Woodhouse Day Spa

Licensed Massage Therapist Full Time Job at The Woodhouse Day Spa

 ...future at Woodhouse! Join our team of full-time Licensed Massage Therapists earn estimated $50k* - $80k* per year PLUS a GENEROUS, WORLD...  ...Requirements: Active Massage Therapist License No job experience necessary, we will train Woodhouse is the leader in affordable... 

Geisinger

Case Manager Job at Geisinger

 ...Prepares the patient and/or family for home care following discharge. Consults with patient's physician in planning and with Care Management regarding support at home as indicated. This role is full-time, 40 hours weekly; days. A Bachelor's Degree (does not have to... 

Lumen Resources

Technical Recruiter (Orlando) Job at Lumen Resources

 ...agency in Central Florida, specializing in connecting top-tier technical talent with leading companies in the Technology sector. At...  ...Qualifications ~2+ years of experience as a Technical Recruiter, or in a similar role, with a focus on IT, software development... 

Dignity Physician Careers

Orthopedic Hand Surgery Physician Job at Dignity Physician Careers

 ...Opportunity Criteria Specialty: Orthopedic Surgery Candidate Type: MD, DO Visas Accepted: No J-1 or H-1B Loan Repayment...  ...providers in the Sacramento region, is seeking a BE/BC Orthopedic Hand Surgeon (hand fellowship required). Join an already... 

Marvin

Winter Seasonal Production Associate Job at Marvin

Marvin, a leading innovator in the window and door manufacturing sector since 1912, seeks a Winter Seasonal Production Associate to join our production team. This role is crucial for augmenting our manufacturing efforts during the busy winter season. The ideal candidate...