Clinical Documentation Specialist – First Reviewer

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Perform initial assessments of patient records and review documentation for primary and secondary diagnoses, as well as procedures, to ensure accurate DRG, ROM, and SOI assignments.

• Conduct follow-up reviews of patient records to assist in establishing working or final DRG assignments upon discharge.

• Engage with physicians to address any missing, ambiguous, or contradictory documentation and secure additional health-record information.

• Detect issues related to diagnostic testing reports and implement established query guidelines and compliance standards.

• Provide education to physicians and healthcare providers on improving clinical documentation and ensuring complete, accurate health-record documentation.

• Participate in departmental meetings and independently investigate clinical topics, coding standards, regulatory policies, trends, and healthcare economics.

• Work in conjunction with coding professionals to align DRGs, rectify discrepancies, and address documentation or communication issues.

• Clarify clinical matters with coding professionals to facilitate precise DRG, SOI, and ROM assignments.

• Support mortality review and risk-adjustment procedures utilizing third-party models.

• Implement evidence-based practices and scientific knowledge within nursing practice while addressing age-specific clinical needs.

• Maintain vigilance and adhere to safety protocols.

• Carry out other assigned responsibilities.

⛳️ Requirements

• Graduate from an accredited nursing school, PA, NP, or medical school, or possess an Associate's degree with CCDS certification from ACDIS.

• A minimum of two years' experience in an acute care environment or relevant experience.

• Necessary professional license and/or certification relevant to the state of employment.

• CCDS certification from the Association of Clinical Documentation Improvement Specialists (ACDIS) or an acceptable medical, physician assistant, physician, registered nurse, advanced practice nurse, APRN, APN, or related state license/credential.

• For Missouri: CCDS, medical degree, physician assistant, physician/surgeon, osteopathic physician, compact-state or Missouri RN, or Missouri nurse practitioner credential.

• For Illinois, Oklahoma, or Wisconsin: relevant CCDS, medical, PA, physician, RN, advanced-practice, APRN/APN, or state-specific professional credential.

• Frequent use of keyboard/data entry.

• Capability to perform necessary lifting, carrying, pushing, pulling, sitting, standing, walking, reaching, and repetitive movements.

• Ability to utilize vision and depth perception, hearing, and speech for effective communication and safety.

🏝️ Benefits

• Paid parental leave: one week for eligible team members for the birth or adoption of children, pro-rated based on FTE.

• Flexible payment options via DailyPay, allowing eligible hourly team members instant access to earned but unpaid base pay prior to payday; fees may apply.

• Upfront tuition assistance through FlexPath Funded for eligible team members.

• Comprehensive benefits package.