SSM HealthSH

RN-Clinical Documentation Specialist

SSM Health
United States only
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Worker Type:

Regular

Job Summary:

Reviews medical record for risk of mortality (ROM) and intensity of services (IOM). Collaborates with physician regarding accurate documentation reflecting the care patient is receiving.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

  • Reviews electronic medical record for principle diagnosis and all CC's (complication or comorbidity) and MCC's (major complication or comorbidity) for documentation opportunities.
  • Collaborates with physicians through queries regarding documentation opportunities.
  • Completes annual education.
  • Active participant with other members of team regarding opportunities for improvement in standard work.
  • Works in a constant state of alertness and safe manner.
  • Performs other duties as assigned.

EDUCATION

  • Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

  • Two years' registered nurse experience

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.

Work Shift:

Day Shift (United States of America)

Job Type:

Employee

Department:

8746010033 Sys Clinical Documentation Improvement

Scheduled Weekly Hours:

40

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.

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About the job

Apply before

Aug 19, 2024

Posted on

Jun 20, 2024

Job type

Full Time

Experience level

Senior

Location requirements

Hiring timezones

United States +/- 0 hours
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