Note The job is a remote job and is open to candidates in USA. SSM Health is a healthcare organization dedicated to providing exceptional care. The Clinical Documentation Specialist, Second Reviewer plays a crucial role in ensuring medical records are complete and accurately represent the health status of patients, collaborating with the interdisciplinary care team to improve documentation and risk adjustment scores.

Responsibilities

• 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. Skills
• 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
• 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)
• 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
• 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)
• 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 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 pro