Facility Clinical Documentation Specialist RN

Job Title

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.

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.

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.

Work Shift: Day

Position Type: Regular Full Time