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RN Clinical Documentation Specialist- Remote
Location
United States
Posted
67 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
RN Clinical Documentation Specialist- Remote
Ochsner Health
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 & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns. Ochsner is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status. Physical and Environmental Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible. Mechanical lifting devices (carts, dollies, etc.) or team lifts should be utilized. Must be able to stoop, bend, reach and grab with arms and hands, manual dexterity. Must be able to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability). Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur. The incumbent works with patients who have known or suspected communicable diseases and may enter isolation rooms. The incumbent has an occupational risk for exposure to all communicable diseases. Are you ready to make a difference? Apply Today! Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website. Please refer to the job description to determine whether the position you are interested in is remote or on-site. Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, and Washington D.C. Ochsner Health endeavors to make our site accessible to all users. If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. Ochsner is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to any legally protected class, including protected veterans and individuals with disabilities.
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The Clinical Documentation Manager uses clinical, ICD coding, government and non-government regulations and experience to perform daily operational management of the CDI program and CDI Staff. DISCLAIMER: This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this intends to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks performed as assigned. Education: High School Diploma or equivalent required. Graduate of an NLN school of nursing or other clinically accredited program preferred. License: If graduate of NLN School of nursing, current Mississippi RN license preferred. Certifications: Clinical documentation Improvement Certification (CCDS or CDIP) and/or Certified Coding Certification (CCS or CIC) preferred. 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