[Hiring] RN-Clinical Documentation Specialist Lead @SSM Health

Role Description

Performs duties of a clinical documentation specialist and serves as a mentor and resource to the clinical documentation improvement team. Assists team managers with the query escalation report, mismatch escalations, reconciliation, query impact, and precepting new hires.

• 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.
• Reconciles reviews and ensures correct query impact.
• Generates and distributes query escalation reports to physician advisors.
• 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.
• Assists with provider education as needed.
• Educates physicians and key healthcare providers regarding clinical documentation improvement (CDI) and the need for accurate and complete documentation in the health record.
• Attends department meetings to review documentation-related issues.
• Trains and mentors new CDI staff on CDI strategy, workflows, and software.
• Partners 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.
• Reviews and clarifies clinical issues in the health record with coding professionals that would support an accurate DRG assignment, SOI, and/or ROM.
• Troubleshoots documentation or communication problems proactively and appropriately escalates.
• Serves as first line of escalation in the mismatch process.
• Acts as a resource and first point of contact for front-line clinical documentation staff for workflow or case reconciliation matters.
• 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.
• As an SSM Health nurse, demonstrates the professional nursing standards defined in the professional practice model.
• Uses the ANA Code of Ethics for Nurses to guide responses to the current and evolving health and nursing needs of patients and patient populations.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

Qualifications

• Graduate of accredited school of nursing or education equivalency for licensing.
• Two years' acute care experience.
• Three years' clinical documentation specialist experience.

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.
• 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.

Benefits

• Paid Parental Leave: one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
• Flexible Payment Options: instant access to earned, unpaid base pay for eligible hourly team members (fees may apply).
• Upfront Tuition Coverage: upfront tuition coverage through FlexPath Funded for eligible team members.