Clinical Documentation Specialist, First Reviewer

📋 Description

• • The Clinical Documentation Specialist, First Reviewer plays a critical role in ensuring accurate clinical documentation that directly impacts patient care quality, reimbursement, and regulatory compliance by reviewing records for completeness and accuracy from admission to discharge.
• • Day-to-day responsibilities include conducting initial and follow-up reviews of patient records to assign accurate DRG, SOI, and ROM codes; querying physicians for missing or unclear documentation; educating healthcare providers on documentation standards; collaborating with coding professionals to resolve discrepancies; and conducting independent research on clinical topics, coding guidelines, and healthcare economics.
• • SSM Health Care Corporation is a mission-driven, integrated health system committed to delivering exceptional care with a focus on clinical excellence, patient safety, and innovation across its hospitals and care sites in the Midwest.
• • In this role, the individual will develop deep expertise in clinical documentation improvement, coding compliance, and healthcare reimbursement systems while building communication and education skills through provider engagement and contributing to quality improvement and risk adjustment initiatives.