RN Clinical Documentation Specialist, First Reviewer

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

MO-REMOTE

Worker Type:

Regular

Job Highlights:

At SSM Health, we believe in providing our employees with a fulfilling career. We strive to create an environment where individuals can grow both personally and professionally. Our company values diversity, innovation, and collaboration, and we are committed to making a positive impact on the communities we serve.

Joining SSM Health means becoming part of a team that is dedicated to providing exceptional patient care and making a difference in people's lives. Our employees are passionate about what they do, and their commitment to our mission is what sets us apart.

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. 

Principal Duties and Responsibilities

Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded. Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.  Assigns a working DRG and severity level using coding rules and guidelines with follow up reviews. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation. Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI). Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing. Utilizes software systems (including DRG encoder) to collect, track, and report outcomes.  Requires proficiency in abstracting and data entry into all databases used for clinical documentation.  Maintains integrity of data collection. Participates in ongoing education of staff.  Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Knowledge and Skills

• ***Candidate must have prior CDI experience***

• Bachelor's Degree in Nursing preferred.
• Three - five years acute inpatient care experience preferred.
• Knowledge of ICD10 coding, as well as strong computer skills preferred, however content training in coding will be provided.

We are hiring for remote workers in 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 (