Facility Clinical Documentation Specialist RN

Job Description

Job Description

Overview

Compensation / Benefits

• $31.31-$51.14/hr based on previous work experience
• Benefits include medical, dental, vision, short-term disability, long-term disability, life insurance, paid time off (PTO), paid holidays, tuition reimbursement, scholarship opportunities, retirement plans, free parking, and opportunities for advancement

Responsibilities

• Improves the overall quality and completeness of clinical documentation by performing systematic chart reviews on a daily basis, querying physicians and proactively soliciting clarification from physicians, as needed.
• Demonstrates knowledge of documentation requirements and coding guidelines that pertain to diagnosis coding to accurately reflect the complexity and medical necessity of the encounter.
• Routinely participates/provides education (including one-on-one education) to physicians, facility/clinic staff and other key healthcare providers.
• Utilizes software systems to collect and ensure the effectiveness of the data.

Qualifications

Education

• Associates Degree in Nursing required, Bachelors of Science in Nursing preferred.

Experience

• 3 to 5 years direct clinical nursing experience required
• Experience in a broad range of clinical situations/settings preferred

(Above requirements can be met by equivalent combination of education and experience)

Licensure/Certification

• Current Oklahoma RN licensure required
• Professional certification in Clinical Documentation, CCDS, CCDS-O or CDIP preferred and/or Professional coding certification, RHIA, RHIT, CCS, CCS-P, COC or CRC preferred

Other Knowledge/Skills/Abilities

• Knowledge of Excel, Microsoft Word, Microsoft PowerPoint and Microsoft Outlook
• Strong interpersonal, communication (verbal and non-verbal and listening) skills
• Experience in developing and presenting education programs
• Analytical skills
• Needs to be self-motivated, self-directed and able to work independently with minimal supervision
• Well organized and detail oriented
• Capable of critical thinking, reasoning, deduction and inference while displaying the ability to draw accurate conclusions
• If not already obtained, certification in Clinical Documentation and/or coding certification is voluntary but highly recommended within 3 - 5 years.