Clinical Documentation Specialist, First Reviewer

SSM Health

Clinical Documentation Specialist conducting analytical reviews of clinical data and improving documentation accuracy. Collaborating with healthcare teams to ensure proper documentation and compliance.

Posted 6/24/2026full-timeRemote • Montana • 🇺🇸 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 and the need for accurate and complete documentation.
Collaborates with 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.
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).
Maintains appropriate productivity level. Conducts follow-up reviews of patients every 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.
Identifies issues with reporting of diagnostic testing proactively. Enhances expertise in query development, presentation, and standards including understanding of published query guidelines and practice expectations for compliance.
Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics.
Collaborates with coding to reconcile the DRG and resolves mismatches utilizing the escalation policy.
Troubleshoots documentation or communication problems proactively and appropriately escalates.
Evaluates clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, SOI, and/or ROM.
Assists in the mortality review and risk adjustment process utilizing third-party models.

Requirements

What you’ll need

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)
Two years' in an acute care setting or relevant experience
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
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

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 improvementdiagnostic codingprocedural codingDRG assignmentrisk of mortality (ROM)severity of illness (SOI)query developmenthealth record evaluationdocumentation guidelinesregulatory policies

Soft Skills

collaborationcommunicationeducationproblem-solvingindependent researchproactive identification of issuesteamworkanalytical thinkingattention to detailorganizational skills

Certifications

Certified Clinical Documentation Specialist (CCDS)Registered Nurse (RN)Physician Assistant (PA)Nurse Practitioner (NP)Advanced Practice Nurse (APN)