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Clinical Documentation Specialist, Second Reviewer

Remote, USA Full-time Posted 2025-11-24
Description: • 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 CMS requirements related to clinical documentation and provides feedback to clinical staff 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. Requirements: • Education: Graduate of accredited school of nursing, PA, NP, or medical school; or Associate's degree and CCDS certification. • Experience: Two years in an acute care setting with two years experience in clinical documentation or 4 years experience in clinical documentation with a CCDS certification. • Licenses/Certifications: Certified Clinical Documentation Specialist (CCDS) - ACDIS; or Physician Assistant in Medicine; or Physician - Regional MSO Credentialing; or Registered Nurse (RN) - IDFPR; or Advanced Practice Nurse (APN) - IDFPR; or APN Controlled Substance - IDFPR; or Full Practice Authority APRN - IDFPR; or Full Practice Authority APRN - IDFPR. • State Licensure/Work Location: State of Work Location: Illinois; Missouri; Oklahoma; Wisconsin and other requirements as applicable. • Physical Requirements: Frequent lifting/carrying 0-25 lbs; Frequent sitting, standing, walking; etc. 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. • Explore All Benefits • SSM Health is an equal opportunity employer. Apply tot his job Apply To this Job

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