RN Clinical Documentation Specialist Lead

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 functions as the liaison between the customers of the CDI Department and the CDI Leadership. Acts as a clinical and technical resource to the CDS staff, answering questions and offering guidance on non-administrative issues; observes, reports, prioritizes and re-routes daily workflow of the department according to Operational Standards under the direction of leadership, and maintains responsibility for running operational reports and forwarding key metrics to leadership at regularly scheduled intervals; facilitates special record reviews, projects and other customer requests of the department, and performs other duties as necessary in support of the department.

Education

Required – Completion of a formal training program in Nursing

Preferred – Bachelor’s degree in Nursing

Work Experience
Required – 3 years clinical experience in an acute care setting including experience in Clinical Documentation Improvement. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.

Certifications

Required – Current registered nurse license

Preferred – Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)

Knowledge Skills and Abilities (KSAs)

• Must have computer skills and dexterity required for data entry and retrieval of patient information. Must be proficient with Windows-style applications and keyboard.
• Effective verbal and written communication skills and the ability to present information clearly and professionally to varying levels of individuals.
• Broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Strong organizational skills
• Excellent written and verbal communication skills
• Self directed

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
• Communicates effectively and appropriately with internal and external customers
• Provides consultation and education to departmental staff.
• Actively supports and participates in physician/hospital performance improvement initiatives.
• Assists department manager in departmental initatives as assigned to enhance overall efforts of the department.

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.

Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid.

The incumbent has no 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.

Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Maryland, New York, 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 504-842-4748 (select option 1) or careers@ochsner.org. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.

We are proud to be an Equal Employment Opportunity and Affirmative Action employer. We are committed to the principles of equal employment opportunity and providing a workplace that is free from discrimination based on race, color, creed, religion, pregnancy status, pregnancy-related conditions, national origin, ancestry, mental or physical disability, medical condition, age, veteran status, military status, citizenship status, marital status, familial status, sexual orientation, gender, gender identity or expression, genetic information, political affiliation, unemployment status, or any other characteristic protected under applicable federal, state or local law. These protections extend to applicants and all employment related decisions. View the EEO is the Law poster and its supplement, as well as the pay transparency policy for more information. 

Affirmative Action Policy Statement