RN-Clinical Documentation Specialist Lead

SSM Health

2d • Remote

About The Position

Performs duties of a clinical documentation specialist and serves as a mentor and resource to the clinical documentation improvement team. Assists team managers with the query escalation report, mismatch escalations, reconciliation, query impact, and precepting new hires.

Requirements

• Graduate of accredited school of nursing or education equivalency for licensing
• Two years' acute care experience
• Three years' clinical documentation specialist experience
• State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration
• State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)
• State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Nice To Haves

• Maintains a level of expertise by attending continuing education programs.

Responsibilities

• Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate Diagnosis Review Group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI).
• Maintains appropriate productivity level.
• Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary.
• Reconciles reviews and ensures correct query impact.
• Generates and distributes query escalation reports to physician advisors.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Identifies issues with reporting of diagnostic testing proactively.
• Assists with provider education as needed.
• Educates physicians and key healthcare providers regarding clinical documentation improvement (CDI) and the need for accurate and complete documentation in the health record.
• Attends department meetings to review documentation related issues.
• Trains and mentors new CDI staff on CDI strategy, workflows, and software.
• Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.
• Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM.
• Troubleshoots documentation or communication problems proactively and appropriately escalates.
• Serves as first line of escalation in the mismatch process.
• Acts as a resource and first point of contact for front-line clinical documentation staff for workflow or case reconciliation matters.
• Assists in the mortality review and risk adjustment process utilizing third-party models.
• Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record.
• Imparts knowledge to providers and other members of the healthcare team.
• Maintains a level of expertise by attending continuing education programs.
• 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.
• As an SSM Health nurse, I will demonstrate the professional nursing standards defined in the professional practice model.
• Uses the ANA Code of Ethics for Nurses to guide his/her response to the current and evolving health and nursing needs of our patients and our patient populations.
• 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: High school or GED