RN Clinical Documentation Specialist Lead- Quality Reviewer

Ochsner Clinic Foundation; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

Ochsner Clinic Foundation in Louisiana seeks a CDI liaison with RN expertise to support the Clinical Documentation Improvement program. You will review records, guide CDS staff, and communicate with physicians and hospital teams to ensure accurate documentation.

Required is nursing program completion and an active Louisiana RN license, with 3 years of acute care experience and knowledge of complex disease processes. CCDS/CDIP credentials are preferred and professional growth is encouraged.

Qualifications

• Must have completed a formal nursing program.
• Active Louisiana RN license required.
• Experience in Clinical Documentation Improvement or acute care setting preferred.
• Strong knowledge of disease processes and inpatient care.
• Effective communication with clinical teams and leadership.

Responsibilities

• Performs medical record review for documentation completeness and accuracy.
• Provides consultation and education to departmental staff.
• Guides CDS staff and physicians on documentation improvement initiatives.
• Supports physician/hospital performance improvement projects.
• Assists manager with department initiatives to enhance overall performance.

Skills

Computer skills

Verbal communication

Written communication

Organizational skills

Clinical knowledge

Education

Nursing program completion

Bachelor's degree in Nursing

Job description

Exceptional care starts with exceptional people.

For us, this is more than a job– it’s a calling. It’s waking up each day, looking for ways to make a difference with a compassionate, inclusive and talented team. Ochsner empowers you to discover your passion, reach your potential, and Pursue Your Purpose. Exceptional care starts with exceptional people and teams. Together we are leading the way.

This job functions as the liaison between the customers of the CDI Department and the CDI Leadership. Acts as a clinical and technical resource to the CDS staff, answering questions and offering guidance on non-administrative issues; observes, reports, prioritizes and re-routes daily workflow of the department according to Operational Standards under the direction of leadership, and maintains responsibility for running operational reports and forwarding key metrics to leadership at regularly scheduled intervals; facilitates special record reviews, projects and other customer requests of the department, and performs other duties as necessary in support of the department.

Education

Required -Completion of a formal training program in Nursing

Preferred -Bachelor's degree in Nursing

Work Experience

Required -3 yearsclinical experience in an acute care setting including experience in Clinical Documentation Improvement. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.

Certifications

Required -Current State of Louisiana Registered Nurse License

Preferred -Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)

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.


• Broad-based clinical knowledge and understanding of pathology/physiology of disease processes.


• Strong organizational skills


• Excellent written and verbal communication skills


• Self directed

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


• Provides consultation and education to departmental staff.


• Actively supports and participates in physician/hospital performance improvement initiatives.


• Assists department manager in departmental initatives as assigned to enhance overall efforts of the department.

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.

Physical and Environmental Demands

The physical essential functions of this job include (but are not limited to) the following: Frequently exerting 10 to 20 pounds of force to move objects; occasionally exerting up to 100 pounds of force. Physical demand requirements are in excess of those for sedentary work. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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.

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 [e-mail]. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.