Clinical Documentation Specialist, First Reviewer

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Clinical Documentation Specialist, First Reviewer

role at

SSM Health

Job Summary Performs concurrent analytical reviews of clinical and coding data to improve physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case‑mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners. Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.

Job Responsibilities and Requirements

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 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.

Required Qualifications

1 year of experience as a Clinical Documentation Specialist.

Additional two years in an acute care setting or relevant experience.

Graduate of an 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).

Preferred Qualifications

CCDS certification.

Proficiency with MS Office tools—especially Excel.

Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews.

Pay Range $74,484.80 – $111,737.60

Eligible Remote States Candidates must reside in one of SSM’s approved states: Alabama, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin.

Benefits

Paid parental leave: one week for eligible team members for newborns or newly adopted children (pro‑rated based on FTE).

Flexible payment options: voluntary benefit through DailyPay giving instant access to earned unpaid base pay.

Upfront tuition coverage through FlexPath for eligible team members.

Required Professional Licenses and Certifications

State of Work Location: Illinois

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)

State of Work Location: Missouri

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

State of Work Location: Oklahoma

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)

State of Work Location: Wisconsin

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

Work Shift Day Shift (United States of America)

Job Type Employee

Department 8746010033 Sys Clinical Documentation Improvement

Scheduled Weekly Hours 40

Seniority Level Entry level

Employment Type Full‑time

Job Function Research, Analyst, and Information Technology

Industries Hospitals and Health Care

Equal Opportunity Employer 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.

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