RN Clinical Documentation Specialist Lead- Quality Reviewer - Remote

Ochsner Health; United States; À distance; USD 85 000 - 110 000; Plein temps

Résumé du poste

Ochsner Health in Louisiana seeks a Clinical Documentation Improvement (CDI) Nurse to bridge clinicians and CDI leadership. You will review medical records, provide guidance to CDS staff, and ensure documentation accuracy and compliance.

Requires RN license in Louisiana, 3 years of acute care clinical experience with CDI, and CCDS/CDIP preferred. The role emphasizes collaboration, education, and participation in performance improvement initiatives.

Qualifications

• Completion of a formal training program in Nursing.
• Preferred Bachelor’s degree in Nursing.
• 3 years clinical experience in an acute care setting including Clinical Documentation Improvement.

Responsabilités

• Performs medical record review for documentation completeness and accuracy.
• Communicates effectively with internal and external customers.
• Provides consultation and education to departmental staff.
• Supports physician/hospital performance improvement initiatives.
• Assists department manager in departmental initiatives.

Connaissances

Clinical Documentation

Verbal/written communication

Nursing knowledge

Data entry

Organizational skills

Formation

Nursing training program

Bachelor's in Nursing

Description du poste

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.

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 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 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.

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.