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

Advantage Solutions

In-Store Free Sample Associate Job at Advantage Solutions

Join the dynamic team at Advantage Solutions, a leader in outsourced sales and marketing solutions, as an In-Store Free Sample Associate. This role is crucial in enhancing the shopping experience by engaging customers with product demonstrations and samples in a retail... 

Philadelphia Housing Authority

Public Safety and Crime Analyst Job at Philadelphia Housing Authority

 ...evaluates data and information to assist in the resolution of criminal investigations and inform strategic decision making for the Philadelphia...  .... Minimum education Bachelors Degree in Criminal Justice, Information Systems, Public Administration, Computer Science... 

CXI Trucking

Class C Driver STRAIGHT TRUCK DRIVER- TEC - Elgin, IL. Job at CXI Trucking

 ...Class C Straight Truck - Elgin, IL. CXI Trucking is growing and we have an immediate need for a dedicated Class C Driver in Elgin, IL. for a dedicated account. Start time: 6am Start your day Monday thru Friday in Elgin, IL. and finish your day in Elgin, IL.... 

New Perspective Senior Living

Concierge Job at New Perspective Senior Living

 ...servant leadership and collaboration that supports each team members personal and professional development. At New Perspective youre not just an employee, you are a valued member of our team./ppAs the Concierge, you will provide exceptional first impressions, act as the... 

TradeJobsWorkforce

Costco Meat Cutter Job at TradeJobsWorkforce

Now hiring an experienced Costco Meat Cutter to perform daily responsibilities with dedication. Stay adaptable in a dynamic, fast-paced environment. Work with your team to maintain efficiency and service quality. Perks include competitive pay, flexible schedules, hands...