Clinical Documentation Specialist

At Singing River Health System, caring isn’t just part of the job — it’s in our DNA. Whether we’re saving lives, supporting behind the scenes, or showing up for our community, we bring the energy, heart, and hustle every single day. With pride, passion, and commitment, we will improve health and save lives in our community every day.

Shift: Day Shift; 5-6 days per week depending on need.

Location:

Remote Alabama, Remote Florida, Remote Georgia, Remote Louisiana, Remote Mississippi, Remote North Carolina, Remote South Carolina, Remote Tennessee, Remote Texas.

The Clinical Documentation Specialist improves the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the complexity and severity of illness for a complete and accurate level of service rendered to patients. He/She analyzes the clinical status of patients, current treatment plans and past medical history to identify potential gaps in clinical documentation.

The Clinical Documentation Specialist educates and serves as a clinical liaison to nursing staff and other clinicians on compliant documentation and accurate coding. He/She reconciles DRG differences between the Coding staff and Clinical Documentation Specialist; and monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations.

DISCLAIMER:
This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this intends to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks performed as assigned.

High School graduate or equivalent required. If Registered Nurse, must be a graduate from NLN School of Nursing;
Bachelor of Science in Nursing required.

If Registered Nurse (RN), must hold current applicable license to practice in Mississippi. Current Mississippi RN license preferred.

If not a Registered Nurse, must be certified by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a:

• Registered Health Information Administrator
• Registered Health Information Technician
• Certified Code Specialist
• Certified Inpatient Coder

Must complete all requirements (including continuing education) to maintain certification. CCDS preferred. Must have de-escalation training completed by the end of position orientation (90 days); must have appropriate level of de-escalation training.

A Registered Nurse must have a minimum of two (2) years’ nursing experience in an acute-care facility. Coders must have a minimum of two (2) years’ experience in ICD-9 CM and experience utilizing ICD-10 CM and ICD-10 PCS in an inpatient setting. Must have working knowledge of the AHA Coding Clinic. An understanding of the MS-DRG payment system is required. An understanding of APR-DRG’s preferred.

Clinical Documentation Manager

None

Work is moderately active: involves sitting with frequent requirements to move about the office, move about the facility, and to travel to another facility within the SRHS service area. Work involves exerting a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Work involves using many physical motions in performing daily work activities;

subject to exposure of body fluids, sputum and tissues, which may carry the…