Registered Nurse (RN) - Professional Clinical Documentation Specialist

Norman Regional Hospital Authority•Norman, OK

43d•$24 - $38

About The Position

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. 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.

Requirements

Associates Degree in Nursing required, Bachelors of Science in Nursing preferred.
3 to 5 years direct clinical nursing experience required
Current Oklahoma RN licensure required.
Knowledge of Excel, Microsoft Word, Microsoft PowerPoint and Microsoft Outlook
Strong interpersonal, communication (verbal and non-verbal and listening) skills
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

Nice To Haves

Experience in a broad range of clinical situations/settings preferred
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
Experience in developing and presenting education programs
If not already obtained, certification in Clinical Documentation and/or coding certification is voluntary but highly recommended within 3 - 5 years.

Responsibilities

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.