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Registered Nurse (RN) - Professional Clinical Documentation Specialist

Registered Nurse (RN) - Professional Clinical Documentation Specialist

Norman Regional Health SystemNorman, OK, US
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Job Description

Overview : #HireNRHS

Compensation / Benefits

  • $23.79-$38.36 / hr based on previous work experience
  • Benefits include medical, dental, vision, short-term disability, long-term disability, life insurance, paid time off (PTO), paid holidays, tuition reimbursement, scholarship opportunities, retirement plans, free parking, and opportunities for advancement

Responsibilities : 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
  • (Above requirements can be met by the equivalent combination of education and experience).

    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.
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