Job Description

Weve made a lot of progress since opening the doors in 1942 but one thing has never changed - our commitment to serve heal lead educate 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!

RN Clinical Documentation Specialist

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the companys discretion.

Education

Required -Graduate of an accredited school of nursing.

Work Experience

Required -3 years of clinical experience working with minimal supervision.

Certifications

Required -Current registered nurse license in the state of practice.

A Doctor of Medicine (M.D.) will be accepted in lieu of an RN License **

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.
• Computer skills and dexterity for data entry and retrieval of patient information.
• Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.
• Proficient with Windows-style applications and various software packages specific to role and keyboard.
• Ability to work a flexible work schedule (e.g. 24/7 weekend holiday on call availability).

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.
• Performs 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.
Remains knowledgeable on current federal state and local laws accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws regulations and standards.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety patient privacy and/or other compliance-related concerns.
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 demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Medium Work - Exerting 20 to 50 pounds of force occasionally and/or 10 to 25 pounds of force frequently and/or greater than negligible up to 10 pounds of force constantly to move objects. (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace especially in an industrial setting can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Normal routine involves no exposure to blood body fluid or tissue but exposure or potential for exposure may occur.

The incumbent works with patients who have known or suspected communicable diseases and may enter isolation rooms. There may be an occupational risk for exposure to communicable diseases.

Because the incumbent works within a healthcare setting there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt transport storage preparation dispensing administration cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role.

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.

Please refer to the job description to determine whether the position you are interested in is remote or on-site. Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado California Hawaii Illinois Maryland Massachusetts Minnesota New Jersey New York Vermont 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 (select option 1) or . 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.

Required Experience:

IC

Job Tags

Full time, Work experience placement, Local area, Immediate start, Remote work, Flexible hours, Weekend work,

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