Clinical Documentation Specialist - RN (PRN / Remote)

St. Tammany Parish Hospital • Covington, LA

8d • Remote

About The Position

The Clinical Documentation Specialist (CDS) facilitates improved integrity of medical record documentation by interacting with healthcare providers to support appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care. Using a multidisciplinary team approach, the CDS performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure an accurate depiction of patient complexity and support the facility’s Risk Adjustment strategy.

The CDS applies clinical and nursing knowledge and understanding of complications, comorbidities, severity of illness, risk of mortality, case mix, current CMS coding guidelines, the impact of procedures on the final Diagnosis Related Group (DRG), compliant documentation for Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity. The role collaborates with physicians and advanced practice providers to communicate documentation opportunities and educate patient-care team members on documentation guidelines, coding requirements, and service-line-specific requirements.

The position is listed as PRN and remote, with scheduled weekly hours to be determined. The stated work shift is 8:00 AM–4:30 PM, Monday through Friday.

Requirements

• Graduate of an accredited School of Nursing.
• Current Louisiana Registered Nurse License.
• Five 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 applications (PowerPoint, Excel, and Word), 3M software, and Encoder experience.
• Excellent written and verbal communication, critical-thinking, and interpersonal skills.
• Knowledge of complex disease processes with broad clinical experience in an outpatient setting.
• Ability to work independently with minimal supervision and be self-motivated.
• Proficient organizational and planning skills.

Nice To Haves

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

Responsibilities

• Facilitate improved integrity of medical record documentation through interaction with healthcare providers.
• Support accurate representation of severity of illness, risk of mortality, acuity, and complexity of care.
• Perform pre-visit and retrospective reviews of ambulatory clinical documentation using a multidisciplinary team approach.
• Support the facility’s Risk Adjustment strategy by ensuring documentation accurately depicts patient complexity.
• Collaborate with physicians and advanced practice providers to communicate documentation opportunities.
• Educate members of the patient-care team about documentation guidelines, coding requirements, and service-line-specific requirements.

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed