RN Clinical Documentation Specialist - REMOTE

Ochsner Health; New Orleans (LA); Remote; USD 55,000 - 90,000; Full time

Job summary

Join a forward-thinking healthcare provider dedicated to making a difference in patient care! This role focuses on enhancing the integrity of medical record documentation, providing vital support to healthcare providers. You'll engage in daily evaluations of medical records, ensuring accuracy and compliance with clinical documentation standards. As a key player in improving healthcare quality, you will collaborate with a dynamic team and contribute to performance improvement initiatives. If you're passionate about healthcare and ready to make an impact, this opportunity at Ochsner Health awaits you!

Qualifications

• 3 years experience working with minimal supervision required.
• Current State of Louisiana Registered Nurse License required.

Responsibilities

• Perform medical record review for documentation completeness and accuracy.
• Communicate effectively with internal and external customers.

Skills

Effective verbal communication

Effective written communication

Computer skills for data entry

Interpersonal skills

Education

Registered Nurse Diploma

Tools

Windows-style applications

Job description

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. It presents opportunities and educates providers on quality clinical documentation, serving 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. The role involves performing daily evaluation of medical record documentation to include provider notes, lab results, diagnostic information, and treatment plans, and communicating 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 of mortality, case mix index, secondary diagnoses, and the impact of procedures on the final Diagnosis Related Group (DRG).

Education

Required - Registered Nurse Diploma

Work Experience

Required - 3 years experience working with minimal supervision.

Certifications

Required - Current State of Louisiana Registered Nurse License

Knowledge Skills and Abilities (KSAs)

• Must have computer skills and dexterity required for data entry and retrieval of patient information.
• 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 be proficient with Windows-style applications and various software packages specific to the role.
• 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.

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.

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.

Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Maryland, New York, 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 [e-mail]. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.

We are proud to be an Equal Employment Opportunity and Affirmative Action employer. We are committed to the principles of equal employment opportunity and providing a workplace that is free from discrimination based on race, color, creed, religion, pregnancy status, pregnancy-related conditions, national origin, ancestry, mental or physical disability, medical condition, age, veteran status, military status, citizenship status, marital status, familial status, sexual orientation, gender, gender identity or expression, genetic information, political affiliation, unemployment status, or any other characteristic protected under applicable federal, state or local law. These protections extend to applicants and all employment-related decisions. View the EEO is the Law poster and its supplement, as well as the pay transparency policy for more information.

Affirmative Action Policy Statement