Clinical Documentation Specialist - RN (Remote)

St. Tammany Parish Hospital; Covington (LA); Remote; USD 80,000 - 110,000; Full time

Job summary

The Clinical Documentation Specialist (CDS) at St. Tammany Health System improves the integrity of medical record documentation by collaborating with physicians and care teams to accurately reflect severity of illness, risk of mortality, and care complexity.

This role also conducts pre-visit and retrospective reviews to support the facility's risk adjustment strategy, using ICD-10 guidelines and CMS coding rules to ensure proper DRG impact and HCC capture.

Qualifications

• Valid Louisiana RN license and nursing degree required.
• Minimum five years of clinical experience in acute or ambulatory care.
• Knowledge of ICD-10 coding and Risk Adjustment Coding.

Responsibilities

• Facilitate accurate medical record documentation through collaboration with physicians and care teams.
• Perform pre-visit and retrospective reviews to support risk adjustment strategy.
• Educate providers and staff on documentation guidelines, coding requirements and DRG impact.

Skills

Communication skills

Critical thinking

Interpersonal skills

Independent work

Organizational skills

Education

Louisiana RN License

Bachelor of Science in Nursing (preferred)

Tools

Microsoft Office (PowerPoint, Excel, Word)

3M software

Encoder experience

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 #LI-MB1

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. Please take time to review those expectations, which can be found by clicking here, before applying for employment. If you feel you are unable to demonstrate those characteristics, we respectfully request that you do not proceed with the application process.

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. St. Tammany Health System is a full-service acute care facility that delivers today’s life-improving procedures with the latest technology, highest quality and the utmost care to area residents. From wellness and prevention to diagnosis, treatment, rehabilitation and recovery, the St. Tammany Health System delivers the very latest technology, the most accomplished specialists and highly personalized, caring staff to ensure patients and their families receive world-class healthcare close to home. St. Tammany Health System is an independent service district in a clinically integrated partnership with Ochsner Health System. Together, the two organizations focus on aligning their healthcare offerings to best serve patients and families in west St. Tammany Parish and surrounding areas.