Clinical Documentation Specialist - First Reviewer

SSM Health; United States; Remote; USD 55,000 - 83,000; Full time

Job summary

SSM Health seeks a PRN Clinical Documentation Specialist - First Reviewer to improve physician documentation from entry to discharge, ensuring accurate DRG, SOI, ROM and appropriate reimbursement.

Education: graduate of an accredited nursing, PA, NP or medical school, or an associate degree with CCDS certification from ACDIS. Experience: two years in acute care; prior clinical documentation role required.

Qualifications

• Two years of acute care experience; prior clinical documentation experience required.
• Experience performing concurrent analytical reviews of clinical and coding data.

Responsibilities

• Review clinical data to ensure accurate reflection of patient condition in DRG, SOI and ROM.
• Facilitate queries and educate care team on documentation guidelines for complete health records.

Skills

Clinical Documentation Experience

Education

Nursing/PA/NP/MD Graduate

CCDS Certification

Job description

Put your clinical expertise to work with flexibility. Join SSM Health as a PRN Clinical Documentation Specialist - First Reviewer and help ensure every patient’s story is accurately reflected through complete, precise clinical documentation while supporting quality outcomes and documentation integrity.

Schedule: PRN

Location - Fully Remote for qualified candidates residing in SSM Health's four state footprint. MO, IL, OK or WI.

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.

EDUCATION

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)

EXPERIENCE

• Two years' in an acute care setting or relevant experience
• Prior experience in a Clinical Documentation role is required.