Clinical Documentation Specialist – Second Reviewer

🔥 2 hours ago

🏰 Missouri – Remote

🏰 Missouri – Remote

⏰ Full 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

• Reviews clinical records of both clinical documentation integrity and mortality 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. • Maintains 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.

🎯 Requirements

• 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) • 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.

🏖️ Benefits

• 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.