Job Description

Clinical Documentation Specialist, Second Reviewer at SSM Health summary:

As a Clinical Documentation Specialist and Second Reviewer, I play a crucial role in ensuring that medical records accurately reflect the health status of patients, which is vital for improving documentation outcomes and risk-adjusted scores. My responsibilities include reviewing clinical records for documentation integrity, collaborating with clinical teams on improvement findings, and maintaining compliance with CMS requirements. With a focus on effective communication and program development, I contribute to enhancing the quality of healthcare documentation and education within the organization.

It's more than a career, it's a calling

MO-REMOTE

Worker Type:

Regular

Job Highlights:

Preferred Qualifications:

• CCDS certification
• Prior experience as a Second Level Reviewer
• Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews.
• Proficiency with MS Office Tool - especially Excel.

Candidates are required to reside on one of SSM's approved States:

Alabama, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin.

Job Summary:

Performs as a vital member of the interdisciplinary care team member, an auditor, and an educator ensuring medical records are complete and clinical documentation comprehensively represents the current health status of network patients against ever-changing risk adjusted models. Responsible for achieving improved documentation results and risk adjusted scores for the organization, along with documentation and electronic health record charts that accurately capture the clinical picture.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Reviews clinical records of both c linical d ocumentation i ntegrity and m ortality 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.
• Maintain s 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 patient’s age-specific needs and clinical needs as described in the department's scope of service.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

EDUCATION

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

EXPERIENCE

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

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

 
State of Work Location: Illinois

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• Or
• Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR)
• Or
• Physician - Regional MSO Credentialing
• Or
• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• Or
• Advanced Practice Nurse (APN) - Illinois Department of Financial and Professional Regulation (IDFPR)
• Or
• APN Controlled Substance - Illinois Department of Financial and Professional Regulation (IDFPR)
• Or
• Full Practice Authority APRN Control Substance - Illinois Department of Financial and Professional Regulation (IDFPR)
• Or
• Full Practice Authority APRN - Illinois Department of Financial and Professional Regulation (IDFPR)

State of Work Location: Missouri

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• Or
• Physician Assistant - Missouri Division of Professional Registration
• Or
• Physician - Regional MSO Credentialing
• Or
• Registered Nurse (RN) Issued by Compact State 
• Or
• Registered Nurse (RN) - Missouri Division of Professional Registration
• Or
• Nurse Practitioner - Missouri Division of Professional Registration
• Or
• Registered Nurse Practitioner - Missouri Division of Professional Registration

State of Work Location: Oklahoma

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• Or
• Acknowledgement of Receipt of Application for Physician Assistant - Oklahoma Medical Board
• Or
• Physician Assistant - Oklahoma Medical Board
• Or
• Physician - Regional MSO Credentialing
• Or
• Registered Nurse (RN) Issued by Compact State 
• Or
• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)
• Or
• Advanced Practice Registered Nurse (APRN) - Oklahoma Board of Nursing (OBN)
• Or
• Certified Family Nurse Practitioner (FNP-C) - American Academy of Nurse Practitioners (AANP)

State of Work Location: Wisconsin

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
• Or
• Physician Assistant - Wisconsin Department of Safety and Professional Services
• Or
• Physician - Regional MSO Credentialing
• Or
• Registered Nurse (RN) Issued by Compact State 
• Or
• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services
• Or
• Advanced Practice Nurse Prescriber (APNP) - Wisconsin Department of Safety and Professional Services

Work Shift:

Day Shift (United States of America)

Job Type:

Employee

Department:

8746010033 Sys Clinical Documentation Improvement

Scheduled Weekly Hours:

40

Benefits:

SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.

• Paid Parental Leave : we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE). 

• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.

• Upfront Tuition Coverage : we provide upfront tuition coverage through FlexPath Funded for eligible team members. 

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status , or any other characteristic protected by applicable law. Click here to learn more.

Keywords:

Clinical Documentation Specialist, CCDS certification, Healthcare documentation, Risk adjustment, Patient safety indicator, Medical records review, CMS requirements, Clinical documentation improvement, Interdisciplinary care team, Healthcare compliance

Job Tags

Hourly pay, Full time, Remote job, Flexible hours, Shift work, Day shift,

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