SSM Health
PRN -Clinical Documentation Specialist, First Reviewer
SSM Health, Oklahoma City, Oklahoma, United States
PRN -Clinical Documentation Specialist, First Reviewer
Join to apply for the PRN -Clinical Documentation Specialist, First Reviewer role at SSM Health.
Job Summary Performs analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge, ensuring accurate reflection in diagnosis related group (DRG) assignments, case mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates query resolution and educates the patient care team on documentation guidelines and need for accurate and complete documentation.
Responsibilities
Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, ROM, and SOI.
Conducts follow-up reviews of patients upon discharge to support and assign a working or final DRG assignment.
Queries physicians regarding missing, unclear, or conflicting documentation and obtains additional documentation within the health record when needed.
Educates physicians and key healthcare providers regarding clinical documentation improvement.
Attends department meetings to review documentation related issues.
Collaborates with coding to reconcile DRG and resolves mismatches utilizing the escalation policy.
Reviews and clarifies clinical issues in the health record with coding professionals to support accurate DRG assignment, SOI, and ROM.
Assists in mortality review and risk adjustment process utilizing third-party models.
Imparts knowledge to providers and other members of the healthcare team and maintains expertise through continuing education.
Performs other duties as assigned.
Education & Qualifications 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 Specialists (ACDIS).
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) – 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) – IDFPR or Advanced Practice Nurse (APN) – IDFPR or APN Controlled Substance – IDFPR or Full Practice Authority APRN Control Substance – IDFPR or Full Practice Authority APRN – IDFPR.
State of Work Location: Missouri – Certified Clinical Documentation Specialist (CCDS) – 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.
State of Work Location: Oklahoma – Certified Clinical Documentation Specialist (CCDS) – ACDIS 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).
State of Work Location: Wisconsin – Certified Clinical Documentation Specialist (CCDS) – 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.
Work Shift PRN / Per Diem Shift (United States of America).
Benefits
Paid Parental Leave: one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
Flexible Payment Options: voluntary benefit through DailyPay offering eligible hourly team members instant access to earned, unpaid base pay (fees may apply).
Upfront Tuition Coverage: upfront tuition coverage through FlexPath Funded for eligible team members.
EEO Statement SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.
#J-18808-Ljbffr
Job Summary Performs analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge, ensuring accurate reflection in diagnosis related group (DRG) assignments, case mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates query resolution and educates the patient care team on documentation guidelines and need for accurate and complete documentation.
Responsibilities
Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, ROM, and SOI.
Conducts follow-up reviews of patients upon discharge to support and assign a working or final DRG assignment.
Queries physicians regarding missing, unclear, or conflicting documentation and obtains additional documentation within the health record when needed.
Educates physicians and key healthcare providers regarding clinical documentation improvement.
Attends department meetings to review documentation related issues.
Collaborates with coding to reconcile DRG and resolves mismatches utilizing the escalation policy.
Reviews and clarifies clinical issues in the health record with coding professionals to support accurate DRG assignment, SOI, and ROM.
Assists in mortality review and risk adjustment process utilizing third-party models.
Imparts knowledge to providers and other members of the healthcare team and maintains expertise through continuing education.
Performs other duties as assigned.
Education & Qualifications 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 Specialists (ACDIS).
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) – 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) – IDFPR or Advanced Practice Nurse (APN) – IDFPR or APN Controlled Substance – IDFPR or Full Practice Authority APRN Control Substance – IDFPR or Full Practice Authority APRN – IDFPR.
State of Work Location: Missouri – Certified Clinical Documentation Specialist (CCDS) – 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.
State of Work Location: Oklahoma – Certified Clinical Documentation Specialist (CCDS) – ACDIS 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).
State of Work Location: Wisconsin – Certified Clinical Documentation Specialist (CCDS) – 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.
Work Shift PRN / Per Diem Shift (United States of America).
Benefits
Paid Parental Leave: one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
Flexible Payment Options: voluntary benefit through DailyPay offering eligible hourly team members instant access to earned, unpaid base pay (fees may apply).
Upfront Tuition Coverage: upfront tuition coverage through FlexPath Funded for eligible team members.
EEO Statement SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.
#J-18808-Ljbffr