临床文档专员，二次审核员
Clinical Documentation Specialist, Second Reviewer
这不仅是一份职业，更是一份使命。
MO-REMOTE
职位类型：
全职
职位概述：
作为跨学科护理团队的重要成员、审计员和教育者，确保医疗记录完整，临床文档全面反映网络患者当前的健康状况，符合不断变化的风险调整模型。负责实现组织的改进文档结果和风险调整评分，以及准确捕捉临床情况的文档和电子健康记录图表。
工作职责与要求：
主要职责
- 审查临床记录，包括临床文档完整性和死亡率评分。
- 与其他人员协作，讨论临床文档改进（CDI）和风险调整（死亡率）发现。
- 了解与临床文档相关的医疗保险和医疗补助服务中心（CMS）要求，并在同步记录审查过程中向临床工作人员提供有关这些要求的反馈。
- 了解死亡率模型、观察率/预期率（O/E比率）、行业趋势、变量和诊断分组（DRG）频率。
- 作为编码人员和医生之间的联络人。识别并启动新项目开发或项目扩展的机会，以及基于结果分析的项目流程改进机会。
- 与其他团队成员讨论标准工作的改进机会。
- 维护文档，记录调整后的风险和CDI机会。
- 将现有的循证实践和医疗科学知识应用于护理实践，确保护理服务基于患者年龄特定需求和临床需求，如部门服务范围所述。
- 保持高度警觉和安全的工作状态。
- 执行其他指派的任务。
教育背景
- 护理学校、医师助理（PA）、护士执业者（NP）或医学院的毕业生，或获得副学士学位并取得临床文档改进专家协会（ACDIS）颁发的认证临床文档专家（CCDS）证书
- 工作经验
- 在急性护理环境中工作两年，且有两年临床文档经验；或具有四年临床文档经验并持有认证临床文档专家（CCDS）证书
- 身体要求
查看英文原文
It's more than a career, it's a calling.
MO-REMOTEWorker Type:
RegularJob Summary:
Performs as a vital member of the interdisciplinary care team member, an auditor, and an educator ensuring medical records are complete and clinical documentation comprehensively represents the current health status of network patients against ever-changing risk adjusted models. Responsible for achieving improved documentation results and risk adjusted scores for the organization, along with documentation and electronic health record charts that accurately capture the clinical picture.Job Responsibilities and Requirements:
PRIMARY RESPONSIBILITIES
- Reviews clinical records of both clinical documentation integrity and mortality scoring.
- Collaborates with others regardingclinical 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 membersregarding opportunities for improvement in standard work.
- Maintainsdocumentation, logsadjusted 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.
EDUCATION
- 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)
- EXPERIENCE
- Two years in an acute care setting with two years experiencein clinical documentation or 4 years experience in clinical documentation with a Certified Clinical Documentation Specialist (CCDS) certification
- PHYSICAL REQUIREMENTS
- Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
- Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
- Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
- Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
- Frequent keyboard use/data entry.
- Occasional bending, stooping, kneeling, squatting, twisting and gripping.
- Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
- Rare climbing.
REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS
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
Work Shift:
Day Shift (United States of America)Job Type:
EmployeeDepartment:
8746010033 Sys Clinical Documentation ImprovementScheduled Weekly Hours:
40Benefits:
SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.
- 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.
Explore All Benefits
SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity,pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.
Originally posted on Himalayas