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Clinical Documentation Specialist - First Reviewer
Join a team where your work matters—every moment, every patient, every community. At SSM Health, you’ll be empowered to grow, supported to thrive, and inspired to make a lasting impact.
As a Clinical Documentation Specialist - First Reviewer, you will play a vital role in ensuring the accuracy, completeness, and integrity of the medical record. Working closely with physicians and clinical teams, you'll review documentation concurrently to identify opportunities for clarification, support appropriate clinical specificity, and help ensure quality patient care, accurate coding, and regulatory compliance. This role is ideal for a detail-oriented clinical professional who enjoys combining critical thinking, clinical expertise, and collaboration to drive meaningful outcomes across the healthcare continuum.
Schedule: PRN
Location - Fully Remote for qualified candidates residing in SSM Health's four state footprint. MO, IL, OK or WI.
Qualifications: Prior experience in a Clinical Documentation role is required.
Apply today. SSM Health – We bring out the incredible in you, everyday.
Job Summary:
Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES
- Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate diagnosis review group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI). Maintains appropriate productivity level.
- Conducts follow-up reviews of patients every to support and assign a working or final DRG assignment upon patient discharge, as necessary.
- Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Identifies issues with reporting of diagnostic testing proactively. Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance.
- Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
- Attends department meetings to review documentation related issues. Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
- Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy. Troubleshoots documentation or communication problems proactively and appropriately escalates.
- Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM. Assists in the mortality review and risk adjustment process utilizing third-party models.
- Demonstrates an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record. Imparts knowledge to providers and other members of the healthcare team. Maintains a level of expertise by attending continuing education programs.
- 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 or relevant experience
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
- Medical Degree - Doctorate's degree
- Or
- Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR)
- Or
- Physician, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR)
- 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
- Medical Degree - Doctorate's degree
- Or
- Physician Assistant - Missouri Division of Professional Registration
- Or
- Medical Physician/Surgeon Temporary - Missouri Division of Professional Registration
- Or
- Medical Physician & Surgeon - Missouri Division of Professional Registration
- Or
- Osteopathic Physicians - Missouri Division of Professional Registration
- 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
State of Work Location: Oklahoma
- Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS)
- Or
- Medical Degree - Doctorate's degree
- Or
- Acknowledgement of Receipt of Application for Physician Assistant - Oklahoma Medical Board
- Or
- Physician Assistant - Oklahoma Medical Board
- Or
- Medical Physician - Oklahoma Board of Medical Licensure and Supervision
- Or
- Osteopathic Physician & Surgeon - Oklahoma State Board of Osteopathic Examiners
- 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
- Medical Degree - Doctorate's degree
- Or
- Physician Assistant (PA) - Wisconsin Department of Safety and Professional Services
- Or
- Physician - Wisconsin Department of Safety and Professional Services
- 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:
PRN / Per Diem Shift (United States of America)Job Type:
Department:
SSM Health is an Equal Opportunity Employer. SSM Health provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender, pregnancy, sexual orientation, gender identity, national origin, age, disability, protected veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law. Click here to learn more.
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