Clinical Documentation Specialist - RN (Remote)

St. Tammany Parish Hospital • Covington, LA

2d • Remote

About The Position

At St. Tammany Health System, delivering world-class healthcare close to home is our goal. We are committed to attracting and retaining the very best professionals for every position in our health system. The health system is nestled in the heart of Covington on the north shore of Lake Pontchartrain. It is a peaceful, scenic, community-oriented area with an abundance of amenities to suit every taste. The Clinical Documentation Specialist (CDS) facilitates the improved integrity of medical record documentation through interaction with healthcare providers to support the appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care. In addition, the CDS, through a multidisciplinary team approach, performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure an accurate depiction of the true complexity of the patient to support the facilities Risk Adjustment strategy. The CDS utilize their clinical/nursing knowledge, and demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, current CMS coding guidelines, the impact of procedures on the final Diagnosis Related Group (DRG), compliant documentation to support the capture of Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity. Lastly, they work collaboratively with all physicians and advanced practice providers to communicate opportunities and educate members of the patient care team regarding documentation guidelines, coding requirements and service-line specific requirements.

Requirements

• Graduate of an accredited School of Nursing and current Louisiana Registered Nurse License required.
• Five (5) years of clinical experience in an acute or ambulatory care setting.
• Knowledge of ICD-10 coding principles and guidelines and Risk Adjustment Coding.
• Proficiency in Microsoft Office Application (PowerPoint, Excel, Word), 3M software, and Encoder experience.
• Excellent written and verbal communication skills, critical thinking skills and interpersonal skills.
• Knowledge of complex disease processes with a broad clinical experience in an outpatient setting.
• Works independently with minimal supervision and self-motivated.
• Proficient organizational and planning skills.

Nice To Haves

• Bachelor of Science degree in Nursing preferred.
• Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing and auditing preferred.
• RN with Current Certified Clinical Documentation Specialist (CCDS) through Association for Clinical Document Improvement Specialists (ACDIS) preferred.

Responsibilities

• Facilitate the improved integrity of medical record documentation through interaction with healthcare providers to support the appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care.
• Perform pre-visit and retrospective reviews of ambulatory clinical documentation to ensure an accurate depiction of the true complexity of the patient to support the facilities Risk Adjustment strategy.
• Utilize clinical/nursing knowledge to demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, current CMS coding guidelines, the impact of procedures on the final Diagnosis Related Group (DRG), compliant documentation to support the capture of Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity.
• Work collaboratively with all physicians and advanced practice providers to communicate opportunities and educate members of the patient care team regarding documentation guidelines, coding requirements and service-line specific requirements.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level