Senior Clinical Documentation Specialist

Ascension; St. Louis (MO); Sur place; USD 85 000 - 110 000; Plein temps

Avantages offerts par ce poste

Health coverage

403(b) retirement plan

PTO and holidays

Tuition reimbursement

Employee assistance program

Parental leave

Additional insurance options

Transportation benefits

Résumé du poste

Ascension is seeking an experienced Clinical Documentation Integrity (CDI) professional to lead and mentor across CDI departments. You will drive accurate documentation, collaborate with physicians, and ensure compliance with coding guidelines and regulatory standards.

The role emphasizes expertise in CDI practices, quality improvement, and sharing knowledge with colleagues to enhance documentation quality and patient care outcomes.

Qualifications

• Clinical Documentation Specialist credential from ACDIS or equivalent.
• Experience in CDI practices and provider collaboration.
• Knowledge of coding guidelines and regulatory standards.
• Leadership or mentoring experience preferred.
• Strong attention to detail and accuracy.

Responsabilités

• Facilitates clinical documentation to support accurate coding and diagnosis capture.
• Analyzes medical record documentation to identify potential diagnoses and complications.
• Interacts with physicians to obtain detailed information per guidelines.
• Participates in quality improvement projects for documentation practices.
• Shares expertise in clinical documentation and coding with staff and stakeholders.
• Assesses impact of comorbidities and procedures on DRG outcomes.

Connaissances

CDI knowledge

Coding guidelines

Physician collaboration

Mentoring

Quality improvement

Formation

High School diploma or equivalent

Associate's degree

Bachelor's degree

Leadership/management experience

Description du poste

Your future role at a glance

Manages high-complexity cases, leads key initiatives, and serves as a subject matter expert and mentor within the Clinical Documentation Integrity (CDI) departments across markets. Demonstrates expertise in CDI practices, coding guidelines, and provider collaboration to facilitate complete and accurate medical record documentation.

How you’ll make an impact in this role

• Facilitates clinical documentation to support diagnosis capture and to ensure the level of service rendered to patients is accurately recorded and reflected in the medical record.
• Provides expert analysis of medical record documentation for symptoms and clinical indicators to identify potential primary/secondary diagnoses and complications.
• Initiates and maintains interactions with physicians and advanced practice providers to address the need for more detailed information in the medical record. Formulates and distributes physician documentation clarification queries following coding guidelines and applicable compliance standards.
• Participates in quality improvement projects aimed at documentation practices and ensuring compliance with regulatory standards.
• Serves as a subject matter expert in clinical documentation and coding guidelines. Shares knowledge and expertise with colleagues and stakeholders.
• Utilizes knowledge of clinical complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnosis, and impact of procedures on the final diagnosis related group (DRG) to complete CDI work.

What Minimum Requirements You’ll Need

Licensure / Certification / Registration

• Required Credential(s):
• Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.

Education

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree with 1 year of experience OR 5 years of applicable cumulative job specific experience required. 2 years of leadership or management experience preferred.

Benefits that help you thrive

• Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options
• Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance
• Time to recharge: pro-rated paid time off (PTO) and holidays
• Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning
• Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources
• Family support: parental leave, adoption assistance and family benefits
• Other benefits: optional legal and pet insurance, transportation savings and more

Life at Ascension: Where purpose meets opportunity

Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you'll find an inclusive and supportive environment where your contributions truly matter.

Equal employment opportunity employer

Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster.

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