Clinical Documentation Specialist - RN (Remote)

St. Tammany Health System; Covington (LA); On-site; USD 65,000 - 90,000; Full time

Job summary

St. Tammany Health System in Covington, Louisiana seeks a Clinical Documentation Specialist to improve medical record documentation for severity of illness, risk of mortality, and case mix.

The CDS collaborates with physicians and care teams to ensure accurate CMS coding and HCC capture. The role requires an active Louisiana RN license and at least five years in acute or ambulatory care, with ICD-10, 3M, and Encoder proficiency and strong communication.

Qualifications

• RN license required in Louisiana.
• Five years of clinical experience in acute or ambulatory care.
• Knowledge of ICD-10 coding principles and Risk Adjustment Coding.
• Proficiency with Microsoft Office, 3M software and Encoder.

Responsibilities

• Facilitate improved integrity of medical record documentation with providers to support severity of illness, risk of mortality, acuity, and care complexity.
• Perform pre-visit and retrospective reviews to ensure CMS coding accuracy and HCC capture.
• Educate care team on documentation guidelines and coding requirements to support DRG accuracy.

Skills

Written and verbal communication

Independent worker

MS Office proficiency

Education

Louisiana RN license

BSN preferred

Tools

3M software

Encoder experience

Microsoft Office (PowerPoint, Excel, Word)

Job description

At St. Tammany Health System, delivering world-class healthcare close to home is our goal. That means we are committed to attracting and retaining the very best professionals for every position in our health system. We believe the pristine beauty of St. Tammany Parish adds to our attractive compensation package. The health system is nestled in the heart of Covington on the north shore of Lake Pontchartrain. It is a peaceful, scenic, community-oriented area with an abundance of amenities to suit every taste.

Job Description And Position Requirements

Scheduled Weekly Hours: 40

Must have experience in the inpatient coding and documentation areas.

WORK SHIFT:

7:30 AM - 4:00 PM (MON - FRI)

JOB SUMMARY:

The Clinical Documentation Specialist (CDS) facilitates the improved integrity of medical record documentation through interaction with healthcare providers to support the appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care. In addition, the CDS, through a multidisciplinary team approach, performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure an accurate depiction of the true complexity of the patient to support the facilities Risk Adjustment strategy. The CDS utilize their clinical/nursing knowledge, and demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, current CMS coding guidelines, the impact of procedures on the final Diagnosis Related Group (DRG), compliant documentation to support the capture of Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity. Lastly, they work collaboratively with all physicians and advanced practice providers to communicate opportunities and educate members of the patient care team regarding documentation guidelines, coding requirements and service-line specific requirements.

MINIMUM QUALIFICATIONS:

• Graduate of an accredited School of Nursing and current Louisiana Registered Nurse License required. Five (5) 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 Application (PowerPoint, Excel, Word), 3M software, and Encoder experience.
• Excellent written and verbal communication skills, critical thinking skills and interpersonal skills.
• Knowledge of complex disease processes with a broad clinical experience in an outpatient setting.
• Works independently with minimal supervision and self-motivated.
• Proficient organizational and planning skills.

Preferred Qualifications:

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

PHYSICAL DEMANDS:

Must possess good physical health. Some requirements include but are not limited to standing, sitting or walking for long periods of time. Lifting at least 20 pounds is required. Must be able to work with a moderate level of noise.

Physical Effort required:

• Constant (67%-100%) - seeing
• Frequently (34%-66%) - handling/feeling, talking, hearing
• Occasionally (1%-33%) - lifting, carrying, pushing/pulling, stooping, crouching, reaching

Contact Information:

Jennifer Saint, HR Talent Partner

Talent Acquisition - Human Resources

EMPLOYMENT

Each St. Tammany Health System staff member is expected to conduct himself or herself according to our mission, vision and values.

EQUAL OPPORTUNITY EMPLOYER

St. Tammany Health System is an Equal Opportunity Employer. St. Tammany Health System is committed to equal employment opportunity for all employees and applicants without regard to race, color, religion, sex, age, national origin or ancestry, citizenship, sexual orientation, gender identity, veteran status, disability status, genetic information or any other protected characteristic under applicable law.