RN Clinical Documentation Specialist

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 OHS 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).

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 Ochsner's discretion.
 

Education 

Required - High School diploma or equivalent

Work Experience

Required - 3 years experience working with minimal supervision.

Certifications

Required - Current State of Louisiana Registered Nurse License

Basic Life Support (BLS) from the American Heart Association

Knowledge Skills and Abilities (KSAs)

• Must have computer skills and dexterity required for data entry and retrieval of patient information.
• Must be proficient with Windows-style applications and keyboard.
• Effective verbal and written communication skills and the ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.
• Must have computer skills and dexterity required for data entry and retrieval of information
• Must be proficient with Windows-style applications, various software packages specific to role and keyboard
• Excellent written and verbal communication skills
• Good interpersonal skills

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.
•  Communicates effectively and appropriately with internal and external customers.
•  Actively participates as a team member and is accountable for own work responsibilities. 
•  Actively supports and participates in provider/hospital performance improvement initiatives.
•  Demonstrates commitment to continuous self-development with the CDI role.
•  Adapts behavior to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.

Other related duties as required.  The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.

Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

Complies with the Ochsner Health System Compliance & Pri