RN Clinical Documentation Specialist- Remote
Description • Serve as the clinical bridge between bedside care and accurate health information by conducting comprehensive medical record reviews from patient admission through discharge, ensuring every diagnosis, procedure, and treatment is captured with precision and integrity. • Leverage your RN expertise to translate complex clinical scenarios into compliant documentation that directly impacts quality scores, reimbursement accuracy, and population-health analytics for a system that cared for 1.5 million lives in 2023. • Partner with physicians, coders, and care teams in real time—using secure remote technology—to clarify documentation gaps, validate severity of illness, and support optimal DRG assignment while maintaining the highest standards of patient privacy and data security. • Drive continuous performance improvement by identifying trends in documentation deficiencies, presenting actionable insights to hospital leadership, and participating in multidisciplinary PI initiatives that elevate both clinical outcomes and financial stewardship. • Master and maintain proficiency in Windows-based clinical documentation applications, electronic health record systems, and encoder/grouper software, ensuring seamless data retrieval and entry without compromising speed or accuracy. • Adapt communication style to the unique needs of diverse patient populations and provider specialties, demonstrating cultural competence, respect for privacy, and the ability to simplify complex clinical concepts for non-clinical stakeholders. • Uphold federal, state, and local regulations as well as accreditation standards (Joint Commission, CMS, etc.), serving as a compliance champion who immediately reports any suspected unethical or questionable behaviors through Ochsner’s established channels. • Commit to lifelong learning within the Clinical Documentation Integrity (CDI) specialty by attending virtual education sessions, pursuing advanced certifications, and sharing knowledge with peers across 46 hospitals and 370+ care sites. • Maintain flexible availability—including occasional weekends, holidays, or on-call shifts—to meet the 24/7 rhythms of a leading not-for-profit health system recognized as the #1 hospital in Louisiana for 12 consecutive years. • Contribute to Ochsner’s legacy of innovation and service that began in 1942, knowing that every accurately documented chart helps heal patients, strengthen communities, and secure resources for future generations across the Gulf South. Apply tot his job Apply tot his job