RN - Clinical Documentation Specialist

Job Highlights :

At SSM Health, we believe in providing our employees with a fulfilling career. We strive to create an environment where individuals can grow both personally and professionally.

Our company values diversity, innovation, and collaboration, and we are committed to making a positive impact on the communities we serve.

Joining SSM Health means becoming part of a team that is dedicated to providing exceptional patient care and making a difference in people's lives.

Our employees are passionate about what they do, and their commitment to our mission is what sets us apart.

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record.

This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered.

The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Principal Duties and Responsibilities

Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.

Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation.

Assigns a working DRG and severity level using coding rules and guidelines with follow up reviews. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.

Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).

Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG and severity level assignment.

Reviews clinical issues with the coding staff to assign a working DRG. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing.

Utilizes software systems (including DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation.

Maintains integrity of data collection. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Knowledge and Skills

Bachelor's Degree in Nursing preferred.

Three - five years acute inpatient care experience preferred.

Knowledge of ICD10 coding, as well as strong computer skills preferred, however content training in coding will be provided.

We are hiring for remote workers in Missouri, Illinois, Wisconsin, and Oklahoma.

Job Summary :

Reviews medical record for risk of mortality (ROM) and intensity of services (IOM). Collaborates with physician regarding accurate documentation reflecting the care patient is receiving.

Job Responsibilities and Requirements :

PRIMARY RESPONSIBILITIES

• Reviews electronic medical record for principle diagnosis and all CC's (complication or comorbidity) and MCC's (major complication or comorbidity) for documentation opportunities.
• Collaborates with physicians through queries regarding documentation opportunities.
• Completes annual education.
• Active participant with other members of team regarding opportunities for improvement in standard work.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

EDUCATION

Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

Two years' registered nurse 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

Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)

State of Work Location : Missouri

• Registered Nurse (RN) Issued by Compact State
• Registered Nurse (RN) - Missouri Division of Professional Registration

State of Work Location : Oklahoma

• Registered Nurse (RN) Issued by Compact State
• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)

State of Work Location : Wisconsin

• Registered Nurse (RN) Issued by Compact State
• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Work Shift :

Day Shift (United States of America)

Job Type : Employee

Employee