Clinical Documentation Specialist, First Reviewer

SSM Health

Clinical Documentation Specialist performing analytical reviews of clinical documentation to ensure accuracy in coding. Collaborating with healthcare team and coding professionals to enhance documentation practices.

Posted 6/10/2026full-timeRemote • Alabama, Florida, Illinois, Iowa, Kansas, Kentucky, Louisiana, Missouri, Montana, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge.
Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines.
Collaborates with coding professionals to ensure accuracy of diagnostic and procedural data.
Completes initial reviews of patient records and evaluates documentation to assign the principal diagnosis.
Maintains appropriate productivity level.
Conducts follow-up reviews of patients to assign a working or final DRG assignment upon patient discharge.
Queries physicians regarding missing, unclear, or conflicting health record documentation.
Identifies issues with reporting of diagnostic testing proactively.
Enhances expertise in query development, presentation, and standards.
Educates physicians and key healthcare providers regarding clinical documentation improvement.
Attends department meetings to review documentation related issues.
Conducts independent research to promote knowledge of clinical topics and coding guidelines.
Collaborates with coding to reconcile the DRG and resolves mismatches.

Requirements

What you’ll need

Must have prior experience as a Clinical Documentation Specialist
1 year of experience as a Clinical Documentation Specialist
Additional Two years' in an acute care setting or relevant experience
Graduate of accredited school of nursing, PA, NP, or medical school, or Associate's degree and Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialist (ACDIS)
CCDS certification
Proficiency with MS Office Tool - especially Excel.
Prior experience reviewing PSI (patient safety indicator) or experience with Vizient specialized mortality reviews.

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 improvementcoding data analysisdiagnostic and procedural data accuracyprincipal diagnosis assignmentDRG assignmentquery developmentdocumentation guidelinespatient record evaluationreporting of diagnostic testing

Soft Skills

collaborationeducationcommunicationproblem-solvingindependent research

Certifications

Certified Clinical Documentation Specialist (CCDS)