RN Clinical Documentation Specialist

2 hours ago

⚜️ Louisiana – Remote

Although this job is listed in Louisiana, this company may be open to hiring remote in other states.

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Ochsner Health

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Healthcare Insurance • Non-profit • Education

Ochsner Health is a comprehensive healthcare system dedicated to delivering health services to the people of Louisiana, Mississippi, and the Gulf South. Its mission is to serve, heal, lead, educate, and innovate in healthcare. As the largest academic medical center in Louisiana, Ochsner focuses on a clinically-integrated research program aimed at improving community wellness and educating future healthcare leaders. They offer a variety of services, including primary care, urgent care, women's and men's health, digital medicine, and specialized treatments such as cancer care, heart and vascular services, transplants, and more. Ochsner also emphasizes community engagement through partnerships, education, and outreach programs, while fostering an inclusive environment. They are committed to accessibility, patient stories, and transparency in billing and insurance information. Ochsner is a non-profit organization and an equal opportunity employer.

10,000+ employees

Founded 1942

⚕️ Healthcare Insurance

🤝 Non-profit

📚 Education

💰 Grant on 2023-07

📋 Description

• Facilitates the improved integrity of medical record documentation. • Presents opportunities and educates providers on quality clinical documentation and serves as a resource for providers and administrative staff to ensure the clinical documentation within the medical record is accurate and compliant in accordance with internal operating guidelines and regulatory standards (CMS, OIG, ACDIS). • 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 an 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.

🎯 Requirements

• Graduate of an accredited school of nursing. • 3 years of clinical experience working with minimal supervision. • 5 or more years in nursing, coding, case management, utilization review, or clinical documentation improvement experience preferred. • Current registered nurse license in the state of practice. • A Doctor of Medicine (M.D.) will be accepted in lieu of an RN License. • Clinical expertise and knowledge of complex disease processes with a broad clinical experience in a healthcare setting. • 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. • Ability to work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability). • Ability to travel upon request. • Ability to independently manage time in a remote work setting compliant with HIPAA. • Interpersonal skills and ability to educate clinicians on coding and documentation best practices.

🏖️ Benefits

• Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. • This employer maintains and complies with its 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.