RN-Clinical Documentation Specialist Lead
WFA Digital Insight
The demand for skilled clinical documentation specialists has surged, with the healthcare industry experiencing a significant shift towards remote work. As of 2023, the market for healthcare documentation specialists grew by 21%, driven by the need for accurate and efficient patient data management. SSM Health stands out as a leader in this field, prioritizing innovation and excellence. To succeed in this role, candidates will need strong analytical and communication skills, as well as the ability to work independently in a remote setting. With the right expertise, this position offers a unique opportunity to make a meaningful impact on patient care and outcomes.
Job Description
About the Role
The Clinical Documentation Specialist Lead plays a critical role in ensuring the accuracy and completeness of patient records, working closely with healthcare providers to clarify and improve documentation. As a mentor and resource to the clinical documentation improvement team, this position requires strong leadership and communication skills. The successful candidate will be responsible for performing initial reviews of patient records, evaluating documentation, and assigning principal diagnoses and procedures.The role involves working collaboratively with a team of healthcare professionals, including physicians, nurses, and coders, to ensure accurate and compliant documentation. The Clinical Documentation Specialist Lead will also be responsible for generating and distributing query escalation reports, reconciling reviews, and ensuring correct query impact.
SSM Health is a leading healthcare organization committed to delivering high-quality patient care and exceptional service. As a remote worker, the successful candidate will be part of a dynamic team that values innovation, integrity, and teamwork.
What You Will Do
- Perform initial reviews of patient records and evaluate documentation to assign principal diagnoses, secondary diagnoses, and procedures
- Conduct follow-up reviews of patients to support and assign working or final DRG assignments upon patient discharge
- Reconcile reviews and ensure correct query impact
- Generate and distribute query escalation reports to physician advisors
- Query physicians regarding missing, unclear, or conflicting health record documentation
- Identify issues with reporting of diagnostic testing proactively
- Assist with provider education as needed
- Educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation
- Attend department meetings to review documentation-related issues
- Train and mentor new CDI staff on CDI strategy, workflows, and software
- Partner with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation
What We Are Looking For
- Graduate of an accredited school of nursing or education equivalency for licensing
- Two years' acute care experience and three years' clinical documentation specialist experience
- Strong analytical and communication skills
- Ability to work independently in a remote setting
- Experience with clinical documentation software and electronic health records
- Certification in clinical documentation improvement (CCDS) or a related field
- Strong leadership and mentoring skills
Nice to Have
- Experience with query escalation and reconciliation
- Knowledge of ICD-10 coding and guidelines
- Experience with data analysis and reporting
Benefits and Perks
- Competitive salary and benefits package
- Remote work opportunities with flexible scheduling
- Professional development and continuing education opportunities
- Collaborative and dynamic work environment
- Access to cutting-edge technology and software
- Comprehensive health insurance and retirement plans
How to Stand Out
- To stand out in this role, focus on developing strong analytical and communication skills, with the ability to work independently in a remote setting.
- Make sure to highlight any experience with clinical documentation software and electronic health records in your application.
- A certification in clinical documentation improvement (CCDS) or a related field can be a significant advantage.
- Be prepared to discuss your experience with query escalation and reconciliation, as well as your knowledge of ICD-10 coding and guidelines.
- When negotiating salary, consider the value of remote work opportunities and flexible scheduling, as well as any additional benefits or perks offered by the company.
- Red flags to watch for include lack of transparency about the company culture or expectations, or unclear communication about the role or responsibilities.
This is a remote position listed on WFA Digital, the platform for professionals who work from anywhere. Browse more remote jobs across all categories.