RN Clinical Documentation Specialist - Jeff Hwy

Hancock Medical Center New Orleans , LA 70130

Posted 4 weeks ago

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 System and discover your future today!

This job facilitates the improved integrity of medical record documentation. Presents opportunities and educates providers on quality clinical documentation, and serves as a resource for providers to link coding guidelines and medical terminology to improve the accuracy and quality of code assignment in accordance with Operational Guidelines. 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 and 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.

Education

Required

  • Graduate of an accredited school of nursing

Work Experience

Required

  • 3 years clinical experience working with minimal supervision

Certifications

Required

  • Current Registered Nurse License in the state of practice

Knowledge Skills and Abilities (KSAs)

  • Clinical expertise and knowledge of complex disease processes with a broad clinical experience in an inpatient setting.

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

  • 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, various software packages specific to role and keyboard.

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

  • Identifies opportunities for improved physician and hospital outcomes and quality documentation.

  • Initiates interaction with providers to obtain clarification of documentation to most accurately represent severity of illness, risk of mortality and acuity and complexity of care.

  • Conducts follow up reviews to ensure points of clarification have been recorded in the medical record.

  • Serves as a resource and communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients.

  • Effectively acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.

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

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.

The employer 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.

Are you ready to make a difference? Apply Today!

Ochsner Health System 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 Service Center at 504-842-4748 (select option 1) or careers@ochsner.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.

EEO is the Law links in English or Spanish.

Affirmative Action Policy Statement


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RN Clinical Documentation Specialist - Jeff Hwy

Hancock Medical Center