RN - Clinical Documentation Specialist, First Reviewer | Remote

It's more than a career, it's a calling

MO-REMOTE

Worker Type:

Regular

Job Highlights:

***Must have prior and direct Clinical Documentation experience***

Preferred Qualifications:

• CCDS certification
• Proficiency with MS Office Tool - especially Excel.
• Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews. 

Required Qualifications:

• 12 months of experience as a Clinical Documentation Specialist
• 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 or relevant experience

Eligible Remote States:

Candidates are required to reside on one of SSM's approved States:

Alabama, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin.

Job Summary:

Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with 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.

Job Responsibilities and Requirements:

PRIMARY 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 every to support and assign a working or final DRG assignment upon patient discharge, as necessary.
• 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. Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Attends department meetings to rev