Job Overview
Location
MO-REMOTE
Job Type
Full-time
Category
Software Engineering
Date Posted
June 3, 2026
Full Job Description
đź“‹ Description
- • Performs concurrent analytical reviews of clinical and coding data to improve physician documentation from point of entry to discharge, ensuring accurate reflection of patient condition in Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement.
- • Completes initial reviews of patient records to assign principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG, ROM, and SOI assignment while maintaining appropriate productivity levels.
- • Conducts follow-up reviews of patients to support and assign a working or final DRG assignment upon patient discharge, as necessary.
- • Queries physicians regarding missing, unclear, or conflicting health record documentation, requesting and obtaining additional documentation when needed.
- • Identifies issues with reporting of diagnostic testing proactively and enhances expertise in query development, presentation, and compliance standards based on published guidelines.
- • Educates attending physicians and allied health practitioners on clinical documentation improvement and the necessity for accurate, complete documentation in the health record.
- • Collaborates with coding professionals to reconcile DRG assignments, resolve mismatches using escalation policies, and troubleshoot documentation or communication problems.
- • Reviews and clarifies clinical issues in the health record with coding teams to support accurate DRG, SOI, and ROM assignments, assisting in mortality review and risk adjustment processes using third-party models.
- • Demonstrates understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on billed records, imparting this knowledge to providers and healthcare team members.
- • Attends department meetings to review documentation-related issues and conducts independent research to stay current on clinical topics, coding guidelines, regulatory policies, and healthcare economics.
- • Applies evidence-based practice and scientific knowledge in nursing care, ensuring services align with patient age-specific and clinical needs as defined by department scope.
- • Works in a constant state of alertness and maintains safe work practices.
- • Performs other duties as assigned.
🎯 Requirements
- • Must have prior experience as a Clinical Documentation Specialist
- • Graduate of accredited school of nursing, PA, NP, or medical school, or Associate’s degree with Certified Clinical Documentation Specialist (CCDS) certification from ACDIS
- • Two years’ experience in an acute care setting or relevant experience
- • Valid state-specific professional license or certification: CCDS, RN, APRN, PA, or Physician (as required by work location state)
- • Proficiency with MS Office tools, especially Excel
- • Prior experience reviewing PSI (patient safety indicator) or Vizient specialized mortality reviews (preferred)
🏖️ Benefits
- • Paid Parental Leave: one week of paid leave for newborns or newly adopted children (pro-rated based on FTE)
- • Flexible Payment Options: voluntary access to earned, unpaid base pay before payday through DailyPay (fees may apply)
- • Upfront Tuition Coverage: funding available through FlexPath Funded for eligible team members
Skills & Technologies
About South Shore Mental Health
South Shore Mental Health is a Massachusetts-based nonprofit provider of outpatient and community mental-health services for children, adults, and families. Founded in 1926, it offers therapy, psychiatry, substance-use treatment, crisis intervention, and early-childhood programs across the South Shore, Cape Cod, and Greater Boston regions. Clinicians use evidence-based practices to address depression, anxiety, trauma, developmental disorders, and serious mental illness, operating clinics, school-based programs, and mobile teams. The organization partners with schools, hospitals, and state agencies to expand access to care and reduce psychiatric hospitalization, emphasizing culturally responsive, person-centered treatment that supports recovery and long-term wellness.
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