Professional Clinical Documentation Integrity RN

Norman Regional; Norman (OK); On-site; USD 43,000 - 70,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Short-term disability

Long-term disability

Life insurance

Paid time off

Paid holidays

Tuition reimbursement

Scholarship opportunities

Retirement plans

Free parking

Opportunities for advancement

Job summary

Norman Regional is seeking a registered nurse with strong clinical documentation and coding knowledge to improve chart quality. You will perform daily chart reviews, query physicians, and educate staff to ensure accurate reflection of encounter complexity and medical necessity.

The role requires 3–5 years of direct nursing experience, an active Oklahoma RN license, and familiarity with Excel, Word, PowerPoint, and Outlook. Day shift, regular full-time position with benefits.

Qualifications

• Associates degree in nursing required; BSN preferred.
• 3–5 years direct clinical nursing experience required.
• Experience in a broad range of clinical settings preferred.

Responsibilities

• Improve quality and completeness of clinical documentation through daily chart reviews.
• Query physicians and clarify documentation to reflect complexity and medical necessity.
• Educate physicians, facility staff, and other providers.
• Utilize software systems to collect and ensure data effectiveness.

Skills

Interpersonal skills

Analytical skills

Education programs

Independent work

Education

Associates Degree in Nursing

Bachelor of Science in Nursing

Tools

Excel

Word

PowerPoint

Outlook

Job description

Departmental Overview

Compensation / Benefits

• $31.31-$51.14/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

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 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.

Work Shift

Day

Position Type

Regular Full Time