RN Clinical Documentation Specialist: Elevate Care & Coding

Santa Barbara Cottage Hospital; United States; Remote; USD 85,000 - 105,000; Full time

Job summary

The Clinical Documentation Specialist (CDS) at St. Tammany Health System enhances the accuracy and completeness of medical record documentation to properly reflect severity of illness, risk of mortality, acuity and care complexity.

The CDS collaborates with physicians and APPs to support DRG accuracy and CMS guidelines. This role conducts pre-visit and retrospective reviews within ambulatory care, educating team members on documentation standards and coding practices to strengthen the facility's

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.

Responsibilities

• Facilitates the improved integrity of medical record documentation through interaction with healthcare providers.
• Performs pre-visit and retrospective reviews to ensure accurate depiction of patient complexity and support risk adjustment strategy.
• Educates physicians and advanced practice providers on documentation guidelines, coding requirements and service-line specifics.

Skills

Critical thinking

Communication skills

Interpersonal skills

Self-motivated

Organizational skills

Planning skills

Independent work

Education

RN license

BSN preferred

CCDS certification preferred

Tools

Microsoft Office (PowerPoint, Excel, Word)

3M software

Encoder experience

Job description

The Clinical Documentation Specialist (CDS) at St. Tammany Health System enhances the accuracy and completeness of medical record documentation to properly reflect severity of illness, risk of mortality, acuity and care complexity.

The CDS collaborates with physicians and APPs to support DRG accuracy and CMS guidelines. This role conducts pre-visit and retrospective reviews within ambulatory care, educating team members on documentation standards and coding practices to strengthen the facility's