RN Clinical Documentation Specialist- Remote

About the position 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. Presents opportunities and educates providers on quality clinical documentation and serves as a resource for providers and administrative staff to ensure the clinical documentation within the medical record is accurate and compliant in accordance with internal operating guidelines and regulatory standards (CMS, OIG, ACDIS). 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. 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 company's discretion.

Responsibilities

• Performs medical record review on patient record to ensure documentation completeness and accuracy in accordance with the Clinical Documentation Program requirements.
• Identifies opportunities for improved physician and hospital outcomes and quality documentation and communicates these opportunities to various clinical and administrative stakeholders.
• 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 for, communicates with, and educates providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for the patient.
• 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.
• 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.

Requirements

• Graduate of an accredited school of nursing.
• 3 years of clinical experience working with minimal supervision.
• Current registered nurse license in the state of practice.
• A Doctor of Medicine (M.D.) will be accepted in lieu of an RN License
• Clinical expertise and knowledge of complex disease processes with a broad clinical experience in a healthcare setting.
• Broad-based clinical knowledge and understanding of chronic disease progressions.
• 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).
• Ability to travel upon request.
• Ability to independently manage time in a remote work setting compliant with HIPAA.
• Interpersonal skills and ability to educate clinicians on coding and documentation best practices.

Nice-to-haves

• 5 or more years in nursing, coding, case, management, utilization review, or clinical documentation improvement experience.

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