Clinical Documentation Specialist - First Reviewer; H

Join a team where your work matters—every moment, every patient, every community. At SSM Health, you’ll be empowered to grow, supported to thrive, and inspired to make a lasting impact.

It's more than a career, it's a calling.

WI-REMOTE

Worker Type: PRN

Schedule:

PRN

Location – Fully Remote for qualified candidates residing in SSM Health's four state footprint. MO, IL, OK or W.

Qualification:

Prior experience in a Clinical Documentation role is required.

As a Clinical Documentation Specialist – First Reviewer, you will play a vital role in ensuring the accuracy, completeness, and integrity of the medical record. Working closely with physicians and clinical teams, you'll review documentation concurrently to identify opportunities for clarification, support appropriate clinical specificity, and help ensure quality patient care, accurate coding, and regulatory compliance. This role is ideal for a detail-oriented clinical professional who enjoys combining critical thinking, clinical expertise, and collaboration to drive meaningful outcomes across the healthcare continuum.

Performs concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Facilitates the resolution of queries and educates members of the patient care team regarding documentation guidelines and the need for accurate and complete documentation in the health record, including attending physicians and allied health practitioners.

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.
• Attends department meetings to review documentation related issues. 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.
• Reviews and clarifies 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.
• Demonstrates an understanding of…