SSM Health
ClinicalDocumentationSpecialist,SecondReviewer
“Clinical Documentation Specialist, Second Reviewer at SSM Health. Skills: Clinical documentation, Risk adjustment, Auditing, Collaboration. Review clinical records. Collaborate on findings”
What You'll Achieve.
Achieving improved documentation results; Achieving improved risk adjusted scores for the organization
Industry & Context.
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.
What They're Looking For.
Must Have
Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification, Two years in an acute care setting with two years experience in clinical documentation or 4 years experience in clinical documentation with a Certified Clinical Documentation Specialist (CCDS) certification, Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Improvement Specialists (ACDIS), Physician Assistant in Medicine, Licensed - Illinois Department of Financial and Professional Regulation (IDFPR), Physician - Regional MSO Credentialing, Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR), Advanced Practice Nurse (APN) - Illinois Department of Financial and Professional Regulation (IDFPR), APN Controlled Substance - Illinois Department of Financial and Professional Regulation (IDFPR), Full Practice Authority APRN Control Substance - Illinois Department of Financial and Professional Regulation (IDFPR), Full Practice Authority APRN - Illinois Department of Financial and Professional Regulation (IDFPR), Physician Assistant - Missouri Division of Professional Registration, Registered Nurse (RN) Issued by Compact State, Registered Nurse (RN) - Missouri Division of Professional Registration, Nurse Practitioner - Missouri Division of Professional Registration, Acknowledgement of Receipt of Application for Physician Assistant - Oklahoma Medical Board, Physician Assistant - Oklahoma Medical Board, Registered Nurse (RN) - Oklahoma Board of Nursing (OBN), Advanced Practice Registered Nurse (APRN) - Oklahoma Board of Nursing (OBN), Certified Family Nurse Practitioner (FNP-C) - American Academy of Nurse Practitioners (AANP), Physician Assistant - Wisconsin Department of Safety and Professional Services, Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services, Advanced Practice Nurse Prescriber (APNP) - Wisconsin Department of Safety and Professional Services
Nice to Have
Certified Clinical Documentation Specialist (CCDS) certification
What You'll Do.
Review clinical records
Collaborate on findings
Maintain knowledge of CMS requirements
Provide feedback to clinical staff
Maintain knowledge of mortality models
Serve as liaison between coding and physicians
Identify opportunities for program development
Identify opportunities for program process improvements
Work with team members on standard work
Maintain documentation
Log CDI opportunities
Apply evidence-based practice
Ensure age-specific care
Ensure clinical needs care
Work in a constant state of alertness
Perform other duties as assigned
How You'll Work.
Team & Collaboration
Collaborates with others regarding clinical documentation improvement (CDI) and risk adjustment (mortality) findings.; Serves as a liaison between coding staff and physicians as appropriate.; Works with other team members regarding opportunities for improvement in standard work.
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