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

IVA'AL SOLUTIONS LLC

Air Force Domestic Abuse Victim Advocate (DAVA) - Mountain Home AFB Job at IVA'AL SOLUTIONS LLC

 ...the following disciplines: Social Work; Psychology; Marriage, Family, and Child Counseling; Counseling or Behavioral Science; Criminal Justice, or related field. Must possess 2 years of experience assisting and providing advocacy services to victims of domestic violence... 

City of Branson

Firefighter Job at City of Branson

Already Trained and Ready to Answer the Call? Join a team where certified firefighters turn training into action and courage into service. If you're already licensed and looking to serve a community that values your skills, your heart, and your heroism this is your moment... 

Head Springs Depot, Inc

Interior Design Sales Consultant Job at Head Springs Depot, Inc

 ...experience. We focus on making your home beautiful with our carefully curated selection of products. Role Description As an Interior Design Sales Consultant, you will be responsible for assisting customers in selecting furniture and home decor that fit their style... 

Yancey Bros. Co.

Electrical Supervisor - First Shift Job at Yancey Bros. Co.

 ...Description Job Description Who We Are: From Georgia. For Georgia. Since 1914 Yancey Bros. Co. has proudly served as the authorized Caterpillar equipment dealer for Georgia, providing our customers with the highest quality sales, parts and service. From Caterpillar heavy... 

Maxion Research

Social Media Study Contributor - Work from Home Job at Maxion Research

 ...looking for temporary, remote, part-time work. The hours are flexible and no previous experience...  ...(About TV, movies or video games) Social Media (the use of different social media...  ...commute needed if you choose to work from home. No minimum hours. You can do this part...