RN Clinical Documentation Specialist | Risk Adjustment Expert

St. Tammany Parish Hospital; United States; Remote; USD 85,000 - 105,000; Full time

Job summary

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

They perform pre-visit and retrospective reviews to support risk adjustment strategies and ensure ICD-10-CM accuracy, DRG impact, and HCC capture. They work with physicians and advanced practice providers to educate on documentation guidelines, coding

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.

Responsibilities

• 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.
• 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 facility's Risk Adjustment strategy.
• Utilizes clinical/nursing knowledge and understanding of CMS coding guidelines, DRG impact, and the capture of HCC, ICD-10-CM accuracy and specificity.
• Educates physicians and APPs on documentation guidelines, coding requirements and service-line specific requirements.
• Collaborates with the care team to identify opportunities for documentation improvement and education.

Skills

ICD-10 coding principles

Risk Adjustment Coding

Critical thinking

Verbal communication

Interpersonal skills

Independent work

Organizational skills

Education

Louisiana RN License

BSN preferred

CCD S certification preferred

Tools

Microsoft Office (PowerPoint, Excel, Word)

3M software

Encoder experience

Job description

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

They perform pre-visit and retrospective reviews to support risk adjustment strategies and ensure ICD-10-CM accuracy, DRG impact, and HCC capture. They work with physicians and advanced practice providers to educate on documentation guidelines, coding