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
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