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

EBSCO

Accounts Payable Specialist Job at EBSCO

 ...products used by hunters, property owners, and others for real-time remote monitoring. We take pride in developing deep user...  ...Moultrie . We're growing, and we're looking for an Accounts Payable Specialist who wants to do more than push invoices. In this... 

Deaconess

Patient Care Technician - Cardiology (PCT) - Gateway - No Experience Required Job at Deaconess

 ...Job Overview: As a Patient Care Technician (PCT), you'll work...  ...will include: Assisting with personal hygiene, including...  ...Education: Basic Life Support: Health Care Provider, within six months...  ...Patient Care Technician, No Experience Required, Paid Training... 

Maxim Healthcare Service

RN Private Duty Nursing - Houston, TX Job at Maxim Healthcare Service

 ...Private duty nursing (PDN) allows medically fragile patients to receive quality, skilled nursing care in the comfort of their home: a setting...  ...Shift Estimated Pay Range Houston TX 77005 LVN/RN g-tube, trach, vent Thurs-Sat nights 7p-7a LVN $27-3... 

Equinox

Personal Trainer, East 63rd Street Job at Equinox

 ...Job Description Job Description What makes Personal Training with Equinox stand out? Equinox is proudly recognized as the industry...  ...Institute. For over twenty years EFTI has elevated our trainers to design comprehensive client fitness programs that are safe,... 

Capital Markets Placement

Package Handler - No Interview Required Job at Capital Markets Placement

 ...for detail Reliable and responsible And a really good pair of sturdy work shoes Industry-leading Benefits: Excellent weekly pay Safe work environment Growth potential* No experience necessary *This is a seasonal role. A seasonal job is a great place...