RN Clinical Documentation Improvement, Level II Reviewer

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

MO-REMOTE

Worker Type:

Regular

Job Highlights:

At SSM Health, we believe in providing our employees with a fulfilling career. We strive to create an environment where individuals can grow both personally and professionally. Our company values diversity, innovation, and collaboration, and we are committed to making a positive impact on the communities we serve.

Joining SSM Health means becoming part of a team that is dedicated to providing exceptional patient care and making a difference in people's lives. Our employees are passionate about what they do, and their commitment to our mission is what sets us apart.

The Clinical Documentation Improvement (CDI) specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of services rendered. The CDI Specialist assesses clinical documentation through extensive review of the medical record, interaction with physicians, nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate.

Principal Duties and Responsibilities

Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded. Collaborates with HIM coding staff to promote complete and accurate clinical documentation and correct negative trends. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation. Assigns a working DRG and severity level using coding rules and guidelines with follow up reviews. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation. Queries physicians on a concurrent basis. Works with physicians to clarify documentation in the medical record. Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI). Conducts post discharge reviews for comparative analysis of CDI Specialist and HIM APR-DRG and severity level assignment. Reviews clinical issues with the coding staff to assign a working DRG. Develops and conducts ongoing education for new staff, including new CDI Specialists, physicians and nursing. Utilizes software systems (including DRG encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation. Maintains integrity of data collection. Participates in ongoing education of staff. Develops educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians presented as handouts, PowerPoint, etc.

Knowledge and Skills

Bachelor's Degree in Nursing preferred.

Three - five years acute inpatient care experience preferred.

Knowledge of ICD10 coding, as well as strong computer skills preferred, however content training in coding will be provided.

***Must have CDI experience***

We are hiring for remote workers in Alabama, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Missouri, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, and Wisconsin.

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 regarding clinical 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 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.

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 experience in 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
• Or
• Registered 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:

Scheduled Weekly Hours:40

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.

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