Clinical Documentation Specialist – Second Reviewer

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

📋 Description

• Analyzes clinical records to ensure clinical documentation integrity and accurate mortality scoring.

• Collaborates with colleagues on findings related to clinical documentation improvement (CDI) and risk adjustment (mortality).

• Keeps up-to-date with Centers for Medicare and Medicaid Services (CMS) requirements concerning clinical documentation and offers feedback to clinical staff during the concurrent record review process.

• Maintains awareness of mortality models, observed versus expected rates (O/E ratios), industry trends, as well as variables and diagnosis review group (DRG) frequency.

• Acts as a liaison between coding personnel and physicians as necessary, identifying and initiating opportunities for new program development or extensions, as well as enhancements based on outcomes analysis for process improvements.

• Collaborates with team members on identifying opportunities for improvement in standard work practices.

• Keeps thorough documentation, logs adjusted risk, and records CDI opportunities.

• Utilizes evidence-based practice and scientific knowledge in health care to inform nursing practice, ensuring nursing care is tailored to patients' age-specific and clinical needs as outlined in the department's scope of service.

• Operates in a state of constant alertness and adheres to safety protocols.

• Performs additional duties as assigned.

⛳️ Requirements

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

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

🏝️ 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 provides eligible hourly team members with instant access to their earned, unpaid base pay (fees may apply) before payday.

• Upfront Tuition Coverage: we offer upfront tuition coverage through the FlexPath Fund for eligible team members.