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SSM Health · 1 day ago

PRN -Clinical Documentation Specialist, First Reviewer

United States

Part-time

Remote

Entry, Mid Level

2+ years exp

SSM Health is a healthcare organization committed to providing quality care. They are seeking a Clinical Documentation Specialist to perform concurrent analytical reviews of clinical and coding data to improve physician documentation and ensure accurate patient condition representation for reimbursement purposes.

Health Care

H1B Sponsor Likely

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

Qualification

Certified Clinical Documentation Specialist (CCDS)Clinical documentation improvementAcute care experienceNursing licenseQuery developmentCollaboration with coding professionalsResearch skillsCommunication skillsAttention to detail

Required

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 or relevant experience

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 provide upfront tuition coverage through FlexPath Funded for eligible team members.

Company

SSM Health

Glassdoor3.4

SSM Health is a Catholic, not-for-profit health system.

Founded in 1872

St Louis, Missouri, USA

10001+ employees

https://www.ssmhealth.com/

H1B Sponsorship

SSM Health has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

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Trends of Total Sponsorships

2025 (1)

2024 (4)

2023 (6)

2020 (2)