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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.
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.
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.
We are hiring for remote workers in Missouri, Illinois, Wisconsin, and Oklahoma.
Job Summary:
Reviews medical record for risk of mortality (ROM) and intensity of services (IOM). Collaborates with physician regarding accurate documentation reflecting the care patient is receiving.Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES
EDUCATION
EXPERIENCE
PHYSICAL REQUIREMENTS
REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS
State of Work Location: Illinois
State of Work Location: Missouri
State of Work Location: Oklahoma
State of Work Location: Wisconsin
Licenses / Certifications:
Registered Nurse (RN) - Missouri Division of Professional Registration, Registered Nurse (RN) - Missouri Division of Professional Registration, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Alabama Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Arizona State Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Arkansas State Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Colorado Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Delaware Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Florida Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Georgia Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Idaho Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Indiana State Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Iowa Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Kansas State Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Kentucky Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Louisiana State Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Maine State Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Maryland Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Mississippi Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Missouri State Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Montana Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - Nebraska Advanced Practice Registered Nurse Board, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - New Hampshire Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - New Jersey Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - New Mexico Board of Nursing, Registered Nurse (RN) Nurse Licensure Compact (NLC) Multi-State - North Carolina Board of Nursing { 15 more}Work Shift:
Day Shift (United States of America)Job Type:
Department:
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.
Full Time
Ambulatory Healthcare Services
$81k-102k (estimate)
01/19/2024
04/29/2024
ssmhealth.com
MONONA, WI
15,000 - 50,000
1874
JAMES RICHARDSONL
$5B - $10B
Ambulatory Healthcare Services
The job skills required for RN - Clinical Documentation Specialist include Patient Care, Collaboration, Communicates Effectively, Integrity, etc. Having related job skills and expertise will give you an advantage when applying to be a RN - Clinical Documentation Specialist. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by RN - Clinical Documentation Specialist. Select any job title you are interested in and start to search job requirements.
The following is the career advancement route for RN - Clinical Documentation Specialist positions, which can be used as a reference in future career path planning. As a RN - Clinical Documentation Specialist, it can be promoted into senior positions as a Head Nurse - CCU that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary RN - Clinical Documentation Specialist. You can explore the career advancement for a RN - Clinical Documentation Specialist below and select your interested title to get hiring information.