Clinical Documentation Specialist, Second Reviewer

This is a fully remote position, open to applicants in Illinois, +3 more states.

📋 Description

• Acts as an integral member of the interdisciplinary care team, serving as an auditor and educator to ensure the completeness of medical records and that clinical documentation accurately reflects the current health status of network patients, adapting to evolving risk-adjusted models.

• Responsible for enhancing documentation outcomes and risk-adjusted scores for the organization while ensuring that documentation and electronic health record charts authentically capture the clinical picture.

• Conducts reviews of clinical records related to clinical documentation integrity and mortality scoring.

• Works collaboratively with others to address clinical documentation improvement (CDI) and risk adjustment (mortality) findings.

• Maintains an understanding of Centers for Medicare and Medicaid Services (CMS) standards associated with clinical documentation and provides constructive feedback to clinical staff during the concurrent record review process.

• Keeps abreast of mortality models, observed/expected rate (O/E ratios), industry trends, and frequency of variable and diagnosis review groups (DRG).

• Serves as a communication bridge between coding staff and physicians when necessary.

• Identifies and initiates opportunities for the development of new programs or extensions, as well as opportunities for process improvements based on outcomes analysis.

• Collaborates with team members to identify areas for enhancement in standard work practices.

• Maintains documentation and logs regarding adjusted risk and CDI opportunities.

• Utilizes established evidence-based practices and scientific knowledge in healthcare to guide nursing practice, ensuring care is tailored to the patient's age-specific and clinical needs as outlined in the department's service scope.

• Operates in a state of constant vigilance and safety.

• Performs additional duties as assigned.

⛳️ Requirements

• Graduate from an accredited nursing school, PA, NP, or medical school, or hold an Associate's degree along with Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS).

• Two years of experience in an acute care environment with two years in clinical documentation, or four years in clinical documentation with CCDS certification.

• 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.

• 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.

🏝️ Benefits

• Paid Parental Leave: Eligible team members receive one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).

• Flexible Payment Options: Our voluntary benefit through DailyPay allows eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) prior to payday.

• Upfront Tuition Coverage: We provide upfront tuition coverage through FlexPath Funded for eligible team members.