Ochsner Health·New Orleans, Louisiana
Facilitates the integrity of medical record documentation by educating providers on quality clinical documentation and linking coding guidelines to medical terminology. Performs daily evaluations of medical records and communicates with providers to clarify or obtain missing documentation to ensure accurate code assignment.
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 to link coding guidelines and medical terminology to improve the accuracy and quality of code assignment in accordance with Operational Guidelines.
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.
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.
Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. (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.
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Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website.
Please refer to the job description to determine whether the position you are interested in is remote or on-site. Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, 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.
Ochsner is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to any legally protected class, including protected veterans and individuals with disabilities.
Requires a graduate degree from an accredited school of nursing or a Doctor of Medicine (M.D.) with a current registered nurse license in the state of practice. Candidates must have at least 3 years of clinical experience working with minimal supervision in an inpatient setting.
Market context
In Louisiana, nursing roles typically see steady demand across hospitals, clinics, and community care settings, especially for RNs with current licensure and recent clinical experience. These roles can be competitive because employers often look for candidates who can start quickly, meet certification and driving requirements, and handle patient care with limited onboarding. Review the AI-summarized requirements and benefits here to save research time, and confirm your RN license, CPR certification, and driver’s license are current before applying.