Clinical Documentation Specialist, Second Reviewer

SSM Health • MO-REMOTE, MO

2d • Remote

About The Position

Performs as a vital member of the interdisciplinary care team member, an auditor, and an educator ensuring medical records are complete and clinical documentation comprehensively represents the current health status of network patients against ever-changing risk adjusted models. Responsible for achieving improved documentation results and risk adjusted scores for the organization, along with documentation and electronic health record charts that accurately capture the clinical picture.

Requirements

• Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS)
• Two years in an acute care setting with two years experience in clinical documentation or 4 years experience in clinical documentation with a Certified Clinical Documentation Specialist (CCDS) certification
• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication.
• Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.
• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR)
• Physician - Regional MSO Credentialing
• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• Advanced Practice Nurse (APN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• APN Controlled Substance - Illinois Department of Financial and Professional Regulation (IDFPR)
• Full Practice Authority APRN Control Substance - Illinois Department of Financial and Professional Regulation (IDFPR)
• Full Practice Authority APRN - Illinois Department of Financial and Professional Regulation (IDFPR)
• Physician Assistant - Missouri Division of Professional Registration
• Registered Nurse (RN) Issued by Compact State
• Registered Nurse (RN) - Missouri Division of Professional Registration
• Nurse Practitioner - Missouri Division of Professional Registration
• Physician Assistant - Oklahoma Medical Board
• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)
• Advanced Practice Registered Nurse (APRN) - Oklahoma Board of Nursing (OBN)
• Certified Family Nurse Practitioner (FNP-C) - American Academy of Nurse Practitioners (AANP)
• Physician Assistant - Wisconsin Department of Safety and Professional Services
• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services
• Advanced Practice Nurse Prescriber (APNP) - Wisconsin Department of Safety and Professional Services

Nice To Haves

• Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS)

Responsibilities

• Reviews clinical records of both clinical documentation integrity and mortality scoring.
• Collaborates with others regarding clinical documentation improvement (CDI) and risk adjustment (mortality) findings.
• Maintains knowledge of Centers for Medicare and Medicaid Services (CMS) requirements related to clinical documentation and provides feedback to clinical staff regarding these requirements during the concurrent record review process.
• Maintains knowledge of mortality models, observed rate/expected rate (O/E ratios), industry trends, variable and diagnosis review group (DRG) frequency.
• Serves as a liaison between coding staff and physicians as appropriate.
• Identifies and initiates opportunities for new program development or program extensions, as well as opportunities based on outcomes analysis for program process improvements.
• Works with other team members regarding opportunities for improvement in standard work.
• Maintains documentation, logs adjusted risk and CDI opportunities.
• Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

Benefits

• one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE)
• instant access to their earned, unpaid base pay (fees may apply) before payday
• upfront tuition coverage through FlexPath Funded for eligible team members

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree