Lead RN, Clinical Documentation Specialist

SSM Health

Clinical Documentation Specialist Lead mentoring teams to improve clinical documentation standards and practices. Handling patient record evaluations and physician education for accurate documentation and coding.

Posted 4/29/2026full-timeRemote • Illinois, Montana, Oklahoma, Wisconsin • 🇺🇸 United StatesSeniorWebsite

About the role

Key responsibilities & impact

Performs duties of a clinical documentation specialist and serves as a mentor and resource to the clinical documentation improvement team.
Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate Diagnosis Review Group (DRG) assignment, risk of mortality (ROM), and severity of illness (SOI).
Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary.
Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
Educates physicians and key healthcare providers regarding clinical documentation improvement (CDI) and the need for accurate and complete documentation in the health record.
Trains and mentors new CDI staff on CDI strategy, workflows, and software.
Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, SOI, and/or ROM.

Requirements

What you’ll need

Graduate of accredited school of nursing or education equivalency for licensing.
Two years' acute care experience and three years' clinical documentation specialist experience.
State of Work Location: Illinois Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
State of Work Location: Missouri Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Missouri Division of Professional Registration.
State of Work Location: Oklahoma Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Oklahoma Board of Nursing (OBN).
State of Work Location: Wisconsin Registered Nurse (RN) Issued by Compact State Or Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services.

Benefits

Comp & perks

Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.
Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical documentation improvementDiagnosis Review Group (DRG) assignmentrisk of mortality (ROM)severity of illness (SOI)patient record evaluationdocumentation queryinghealth record documentationCDI strategyworkflow trainingdiagnostic and procedural data accuracy

Soft Skills

mentoringeducatingcommunicationcollaborationleadership

Certifications

Registered Nurse (RN) - IllinoisRegistered Nurse (RN) - MissouriRegistered Nurse (RN) - OklahomaRegistered Nurse (RN) - Wisconsin