Clinical Documentation Specialist – First Reviewer

🔥 0 minutes ago

🏰 Missouri – Remote

🏰 Missouri – Remote

⏱ Part Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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SSM Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1872

🏥 Healthcare

🤝 Non-profit

💰 Grant on 2023-12

Healthcare • Non-profit

SSM Health is a Catholic, not-for-profit health system serving communities across the U. S. Midwest through an integrated network of hospitals, clinics, and care services. With locations in Illinois, Missouri, Oklahoma, and Wisconsin, SSM Health operates acute-care and specialty services (including teaching hospitals and level‑one trauma centers), emphasizes mission-driven, compassionate care, workforce development, and employee benefits, and supports flexible nursing and other clinical roles.

📋 Description

• Complete initial reviews of patient records and evaluate documentation for principal and secondary diagnoses and procedures supporting accurate DRG, ROM, and SOI assignment • Conduct follow-up patient reviews to support working or final DRG assignment through discharge • Query physicians regarding missing, unclear, or conflicting documentation and obtain additional health-record documentation • Identify diagnostic-testing reporting issues and apply published query guidelines and compliance standards • Educate physicians and healthcare providers on clinical documentation improvement and complete, accurate health-record documentation • Attend department meetings and independently research clinical topics, coding guidelines, regulatory policies, trends, and healthcare economics • Collaborate with coding professionals to reconcile DRGs, resolve mismatches, and escalate documentation or communication problems • Clarify clinical issues with coding professionals to support accurate DRG, SOI, and ROM assignment • Assist with mortality review and risk-adjustment processes using third-party models • Apply evidence-based practice and scientific knowledge to nursing practice and age-specific clinical needs • Maintain alertness and work safely • Perform other assigned duties

🎯 Requirements

• Graduate of an accredited school of nursing, PA, NP, or medical school, or Associate's degree and CCDS certification from ACDIS • Two years' experience in an acute care setting or relevant experience • Required professional license and/or certification appropriate to the state of work location • CCDS certification from the Association of Clinical Documentation Improvement Specialists (ACDIS), or an accepted medical, physician assistant, physician, registered nurse, advanced practice nurse, APRN, APN, or related state license/credential • For Missouri: CCDS, medical degree, physician assistant, physician/surgeon, osteopathic physician, compact-state or Missouri RN, or Missouri nurse practitioner credential • For Illinois, Oklahoma, or Wisconsin: applicable CCDS, medical, PA, physician, RN, advanced-practice, APRN/APN, or state-specific professional credential • Frequent keyboard use/data entry • Ability to perform required lifting, carrying, pushing, pulling, sitting, standing, walking, reaching, and repetitive movements • Ability to use vision and depth perception, hearing, and speech for communication and safety

🏖️ Benefits

• Paid parental leave: one week for eligible team members for newborns or newly adopted children, pro-rated based on FTE • Flexible payment options through DailyPay, providing eligible hourly team members instant access to earned, unpaid base pay before payday; fees may apply • Upfront tuition coverage through FlexPath Funded for eligible team members • Comprehensive benefits package