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

Varite

USA_Developer Job at Varite

 ...ReqID: 10340528 Roles & Responsibilities Experience as a Salesforce Developer in designing and implementing enterprise workflows, CRM solutions, and custom applications on the Salesforce platform. Strong experience in the Software Development Life Cycle (SDLC)... 

Securitas

Overnight Security Officer Job at Securitas

 ...Overnight Security Officer Wage: $16.00-17.00/ hour Must have weekend availability We help make your world a safer place....  ...culture, help define who we are and guide our actions. No experience necessary! If you have retail, food service or hospitality industry... 

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... 

United Scrap Metal, Inc.

Dispatcher Job at United Scrap Metal, Inc.

 ...USM Cicero : Experienced High Volume Dispatcher Over the last forty years, United Scrap Metal (USM) has grown from $200 and a rental truck into one of the largest full-service recyclers in the country. Today, the team continues to pioneer innovative, solutions-driven... 

99 Ranch Market

Night Shift Class C Driver Job at 99 Ranch Market

 ...About the Job: Class C Driver 99 Ranch Market is one of the largest Asian supermarket chains in the United States, with over 60...  ...Manual Transmission. ~ Ability to pass a road test (manual trucks). ~ At least 1 year satisfactory driving record as obtained...