Clinical Documentation Specialist - Second Reviewer

SSM Health; United States; A distancia; USD 90.000 - 120.000; Jornada completa

Descripción de la vacante

SSM Health is seeking a Clinical Documentation Specialist - Second Reviewer to perform advanced reviews ensuring accurate patient narratives in medical records. The role emphasizes inpatient CDI with strong mortality scoring experience and CMS rule compliance.

Remote candidates are welcome if based in WI, OK, IL or MO. A CCDS certification and several years in clinical documentation are highly preferred to support program development and risk adjustment initiatives.

Formación

• Two years in an acute care setting with two years of experience in clinical documentation, or 4 years of experience in clinical documentation with a CCDS certification.

Responsabilidades

• Reviews records for documentation integrity and mortality scoring.
• Collaborates with CDI and mortality findings teams.
• Keeps knowledge of CMS requirements and communicates to staff during reviews.
• Monitors mortality models, O/E ratios, DRG frequency and industry trends.
• Acts as liaison between coding staff and physicians; identifies improvement opportunities.
• Maintains documentation of CDI opportunities and standard-work enhancements.
• Applies evidence-based practice to nursing care aligned with patient age-specific needs.
• Maintains safety and performs other duties as assigned.

Conocimientos

CDI experience

Mortality scoring

CMS requirements

Clinical documentation

Liaison with physicians

Process improvement

Educación

Nursing or allied health degree + CCDS

Herramientas

CCDS certification

Descripción del empleo

Put your clinical expertise and critical thinking to work where accuracy matters. As a Clinical Documentation Specialist - Second Reviewer with SSM Health, you’ll perform advanced reviews that help ensure the patient’s clinical story is accurately and completely reflected in the medical record.

We are looking for a candidate with a strong inpatient, adult CDI background (previous PSI, mortality, and/or SLR experience).

4 years or more of recent CDI experience is preferred.

Remote candidates must live in the following states: WI, OK, IL or MO

Job Duties:

• Reviews clinical records of both clinical documentation integrity and mortality scoring.
• Collaborates with others regarding clinical documentation improvement (CDI) and risk adjustment (mortality) findings.
• Maintains knowledge of Centers for Medicare and Medicaid Services (CMS) requirements related to clinical documentation and provides feedback to clinical staff regarding these requirements during the concurrent record review process.
• Maintains knowledge of mortality models, observed rate/expected rate (O/E ratios), industry trends, variable and diagnosis review group (DRG) frequency.
• Serves as a liaison between coding staff and physicians as appropriate. Identifies and initiates opportunities for new program development or program extensions, as well as opportunities based on outcomes analysis for program process improvements.
• Works with other team members regarding opportunities for improvement in standard work.
  Maintains documentation, logs adjusted risk and CDI opportunities.
• Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patients’ age-specific needs and clinical needs as described in the department’s scope of service.
• Works in a constant state of alertness and in a safe manner.
• Performs other duties as assigned.

EDUCATION

Graduate of an accredited school of nursing, PA, NP, or medical school, or an Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS)

EXPERIENCE

Two years in an acute care setting with two years of experience in clinical documentation, or 4 years of experience in clinical documentation with a Certified Clinical Documentation Specialist (CCDS) certification