Job Description

Join Ochsner Health

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.

Education

Required - Graduate of an accredited school of nursing.

Work Experience

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

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

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 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.

Job Duties

• 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.

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.

Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (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!

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