FREE ACCESS
5,000–10,000 jobs/day
See all jobs on JobTailor
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Clinical Documentation Specialist – Second Reviewer
SSM HealthClinical Documentation Specialist reviewing clinical records and ensuring accurate medical documentation. Collaborating with teams to improve clinical documentation integrity and patient care outcomes.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Improvement (CDI) and risk adjustment, with a strong understanding of CMS requirements and mortality models. Capable of collaborating effectively with clinical staff and coding teams to enhance documentation quality and program development.
Highest-signal resume keywords
Clinical Documentation Improvement (CDI)Certified Clinical Documentation Specialist (CCDS)Mortality ScoringCenters for Medicare and Medicaid Services (CMS)Acute Care Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ReviewMortality ModelsObserved Rate/Expected Rate (O/E Ratios)Diagnosis Review Group (DRG) FrequencyOutcomes Analysis
Soft Skills
CollaborationCommunicationAttention to Detail
Certifications & Qualifications
Certified Clinical Documentation Specialist (CCDS)
Industry Keywords
Clinical Documentation IntegrityRisk AdjustmentEvidence-Based PracticePatient CareProgram Development
About the role
Key responsibilities & impact- Reviews clinical records of both clinical documentation integrity and mortality scoring.
- Collaborates with others regarding clinical documentation improvement (CDI) and risk adjustment (mortality) findings.
- Maintains knowledge of Centers for Medicare and Medicaid Services (CMS) requirements related to clinical documentation and provides feedback to clinical staff regarding these requirements during the concurrent record review process.
- Maintains knowledge of mortality models, observed rate/expected rate (O/E ratios), industry trends, variable and diagnosis review group (DRG) frequency.
- Serves as a liaison between coding staff and physicians as appropriate. Identifies and initiates opportunities for new program development or program extensions, as well as opportunities based on outcomes analysis for program process improvements.
- Works with other team members regarding opportunities for improvement in standard work.
- Maintains documentation, logs adjusted risk and CDI opportunities.
- Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.
- Works in a constant state of alertness and safe manner.
- Performs other duties as assigned.
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 with two years experience in clinical documentation or 4 years experience in clinical documentation with a Certified Clinical Documentation Specialist (CCDS) certification.
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.