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Clinical Documentation Specialist – First Reviewer
SSM HealthClinical documentation specialist improving patient records and DRG accuracy for SSM Health. Reviewing clinical data, querying providers, educating care teams, and collaborating with coders.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, including accurate DRG, SOI, and ROM assignment, while collaborating with healthcare professionals to enhance documentation quality. Holds relevant nursing or medical credentials and applies evidence-based practices in patient care.
Highest-signal resume keywords
CCDS CertificationClinical Documentation ImprovementDRG AssignmentAcute Care ExperienceCollaboration with Coding Professionals
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Patient Record ReviewDocumentation EvaluationDiagnostic Testing ReportingHealth-Record DocumentationMortality ReviewRisk-Adjustment ProcessesData EntryEvidence-Based Practice
Soft Skills
CommunicationEducationProblem-Solving
Certifications & Qualifications
CCDS CertificationProfessional Nursing License
Industry Keywords
Healthcare EconomicsRegulatory PoliciesCoding GuidelinesClinical TopicsAcute Care Setting
About the role
Key responsibilities & impact- Complete initial reviews of patient records and evaluate documentation for principal and secondary diagnoses and procedures supporting accurate DRG, ROM, and SOI assignment
- Conduct follow-up patient reviews to support working or final DRG assignment through discharge
- Query physicians regarding missing, unclear, or conflicting documentation and obtain additional health-record documentation
- Identify diagnostic-testing reporting issues and apply published query guidelines and compliance standards
- Educate physicians and healthcare providers on clinical documentation improvement and complete, accurate health-record documentation
- Attend department meetings and independently research clinical topics, coding guidelines, regulatory policies, trends, and healthcare economics
- Collaborate with coding professionals to reconcile DRGs, resolve mismatches, and escalate documentation or communication problems
- Clarify clinical issues with coding professionals to support accurate DRG, SOI, and ROM assignment
- Assist with mortality review and risk-adjustment processes using third-party models
- Apply evidence-based practice and scientific knowledge to nursing practice and age-specific clinical needs
- Maintain alertness and work safely
- Perform other assigned duties
Requirements
What you’ll need- Graduate of an accredited school of nursing, PA, NP, or medical school, or Associate's degree and CCDS certification from ACDIS
- Two years' experience in an acute care setting or relevant experience
- Required professional license and/or certification appropriate to the state of work location
- CCDS certification from the Association of Clinical Documentation Improvement Specialists (ACDIS), or an accepted medical, physician assistant, physician, registered nurse, advanced practice nurse, APRN, APN, or related state license/credential
- For Missouri: CCDS, medical degree, physician assistant, physician/surgeon, osteopathic physician, compact-state or Missouri RN, or Missouri nurse practitioner credential
- For Illinois, Oklahoma, or Wisconsin: applicable CCDS, medical, PA, physician, RN, advanced-practice, APRN/APN, or state-specific professional credential
- Frequent keyboard use/data entry
- Ability to perform required lifting, carrying, pushing, pulling, sitting, standing, walking, reaching, and repetitive movements
- Ability to use vision and depth perception, hearing, and speech for communication and safety
Benefits
Comp & perks- Paid parental leave: one week for eligible team members for newborns or newly adopted children, pro-rated based on FTE
- Flexible payment options through DailyPay, providing eligible hourly team members instant access to earned, unpaid base pay before payday; fees may apply
- Upfront tuition coverage through FlexPath Funded for eligible team members
- Comprehensive benefits package