[Hiring] Clinical Documentation Specialist @St. Tammany Health System

Role Description

The Clinical Documentation Specialist (CDS) facilitates the improved integrity of medical record documentation through interaction with healthcare providers to support the appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care.

• Performs pre-visit and retrospective reviews of ambulatory clinical documentation.
• Ensures an accurate depiction of the true complexity of the patient to support the facilities Risk Adjustment strategy.
• Utilizes clinical/nursing knowledge and demonstrates an understanding of:
• Complications and comorbidities
• Severity of Illness (SOI)
• Risk of Mortality (ROM)
• Case mix
• Current CMS coding guidelines
• Impact of procedures on the final Diagnosis Related Group (DRG)
• Compliant documentation to support the capture of Hierarchical Condition Categories (HCC)
• ICD-10-CM accuracy and specificity
• Medical necessity
• Works collaboratively with all physicians and advanced practice providers to:
• Communicate opportunities
• Educate members of the patient care team regarding documentation guidelines, coding requirements, and service-line specific requirements

Qualifications

• Graduate of an accredited School of Nursing and current Louisiana Registered Nurse License required.
• Five (5) years of clinical experience in an acute or ambulatory care setting.
• Knowledge of ICD-10 coding principles and guidelines and Risk Adjustment Coding.
• Proficiency in Microsoft Office Application (PowerPoint, Excel, Word), 3M software, and Encoder experience.
• Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills.
• Knowledge of complex disease processes with broad clinical experience in an outpatient setting.
• Works independently with minimal supervision and is self-motivated.
• Proficient organizational and planning skills.

Requirements

• Bachelor of Science degree in Nursing preferred.
• Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, and auditing preferred.
• RN with Current Certified Clinical Documentation Specialist (CCDS) through Association for Clinical Document Improvement Specialists (ACDIS) preferred.

Physical Demands

• Must possess good physical health.
• Some requirements include but are not limited to standing, sitting, or walking for long periods of time.
• Lifting at least 20 pounds is required.
• Must be able to work with a moderate level of noise.

• Physical Effort required:
• Constant (67%-100%) - seeing
• Frequently (34%-66%) - handling/feeling, talking, hearing
• Occasionally (1%-33%) - lifting, carrying, pushing/pulling, stooping, crouching, reaching

Contact Information

Jennifer Saint, HR Talent Partner
Talent Acquisition - Human Resources

Equal Opportunity Employer

St. Tammany Health System is an Equal Opportunity Employer. St. Tammany Health System is committed to equal employment opportunity for all employees and applicants without regard to race, color, religion, sex, age, national origin or ancestry, citizenship, sexual orientation, gender identity, veteran status, disability status, genetic information or any other protected characteristic under applicable law.