RN Clinical Documentation Specialist - Dickory - Full Time

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate.  We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. 

At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters.  Come make a difference at Ochsner Health and discover your future today! 

This job facilitates the improved integrity of medical record documentation. Presents opportunities and educates providers on quality clinical documentation, and serves as a resource for providers to link coding guidelines and medical terminology to improve the accuracy and quality of code assignment in accordance with Operational Guidelines. Performs daily evaluation of medical record documentation to include provider notes, lab results, diagnostic information and treatment plans, and communicates with providers face to face or via query forms to clarify or obtain missing, unclear or conflicting documentation. Demonstrates and understanding of complications, co-morbidities, severity of illness, risk or mortality, case mix index, secondary diagnoses, and the impact of procedures on the final Diagnosis Related Group (DRG) and demonstrates the ability to impart this knowledge to providers, to gather and analyze information pertinent to documentation findings and outcomes.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion.
 

Education

Required - Graduate of an accredited school of nursing.

Work Experience

Required - 3 years of clinical experience working with minimal supervision.

Certifications

Required - Current registered nurse license in the state of practice.

A Doctor of Medicine (M.D.) will be accepted in lieu of an RN License **

Knowledge Skills and Abilities (KSAs)

• Clinical expertise and knowledge of complex disease processes with a broad clinical experience in an inpatient setting.
• Broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Computer skills and dexterity for data entry and retrieval of patient information.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.
• Proficient with Windows-style applications and various software packages specific to role and keyboard.
• Ability to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability).

Job Duties

• Performs medical record review on patient admission and throughout the stay for documentation completeness and accuracy in accordance with the Clinical Documentation Program requirements.
• Identifies opportunities for improved physician and hospital outcomes and quality documentation.
• Initiates interaction with providers to obtain clarification of documentation to most accurately represent severity of illness, risk of mortality and acuity and complexity of care.
• Conducts follow up reviews to ensure points of clarification have been recorded in the medical record.
• Serves as a resource and communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.
• Effectively acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Actively supports and participates