Clinical Documentation Specialist - Second Reviewer

It's more than a career, it's a calling

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Worker Type Regular Job Highlights Join a team where your work matters—every moment, every patient, every community. At SSM Health, you’ll be empowered to grow, supported to thrive, and inspired to make a lasting impact. Schedule Expectation is applicant should be able to work regular business hours M-F (earliest start 6 AM and completed by 6 PM at the latest). Workday should be completed in one sitting with the exception of lunch. Location Remote - the selected candidate is required to live in our four state footprint. MO, OK, IL or WI. Details We are looking for a candidate with strong inpatient, adult CDI background (previous PSI, mortality, and/or SLR experience). 4 years or more of recent CDI experience is preferred. As a Clinical Documentation Specialist - Second Reviewer , you'll play a vital role in ensuring the accuracy, completeness, and integrity of the clinical documentation that supports exceptional patient care. Working collaboratively with Clinical Documentation Integrity (CDI) teams, providers, and coding professionals, you'll perform secondary reviews to identify opportunities for documentation improvement, support accurate quality and reimbursement outcomes, and help strengthen the clinical story of each patient encounter. This role is ideal for a detail-oriented clinical professional who enjoys critical thinking, collaboration, and making a meaningful impact behind the scenes of patient care. Job Summary Performs as a vital member of the interdisciplinary care team member, an auditor, and an educator ensuring medical records are complete and clinical documentation comprehensively represents the current health status of network patients against ever-changing risk adjusted models. Responsible for achieving improved documentation results and risk adjusted scores for the organization, along with documentation and electronic health record charts that accurately capture the clinical picture. Job Responsibilities and Requirements PRIMARY RESPONSIBILITIES Reviews clinical records of both clinical documentation integrity and mortality scoring. Collaborates with others regardingclinical documentation improvement (CDI) and risk adjustment (mortality) findings. Maintains knowledge of Centers for Medicare and Medicaid Services (CMS) requirements related to clinical documentation and provides feedback to clinical staff regarding these requirements 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 membersregarding opportunities for improvement in standard work. Maintainsdocumentation, logsadjusted 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. EDUCATION 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) EXPERIENCE Two years in an acute care setting with two years experiencein clinical documentation or 4 years experience in clinical documentation with a Certified Clinical Documentation Specialist (CCDS) certification 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) - 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 SSM Health is an Equal Opportunity Employer. SSM Health provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, sex, gender, pregnancy, sexual orientation, gender identity, national origin, age, disability, protected veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law. Read our notice of non-discrimination ( #J-18808-Ljbffr SSM Health