Ascension

Clinical Documentation Specialist

Ascension$79K — $110K *
Healthcare
Less than 5 years of experience
Job Overview by Ladders

Qualifications

  • Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or equivalent documentation credential required.
  • Strong background in Clinical Documentation Improvement (CDI) preferred.
  • Experience with second level reviews preferred.
  • Registered Nurse license or Health Information Management credentials accepted.
  • High school diploma and relevant experience or an associate's/bachelor's degree required.

Responsibilities

  • Optimize clinical documentation to enhance medical record accuracy.
  • Manage DRG inputs through timely admission reviews.
  • Collaborate with healthcare providers to resolve documentation queries prior to discharge.
  • Ensure medical records reflect accurate severity of illness and services delivered.
  • Conduct regular assessments to improve data quality in documentation.

Benefits

  • Flexible remote work environment.
  • Full-time schedule offering work-life balance.
  • Collaboration with a multi-disciplinary healthcare team.
Full Job Description
Your future role at a glance

Location: Remote

Facility: Seton Family of Hospital

Department/Specialty: Clinic Integrity Documentation

Schedule: Full time | Monday - Friday | 8:00 am - 4:00 pm CST

Salary: $ 79,511.52 - $110,834.59

How you'll make an impact in this role

  • Optimize Clinical Documentation : Drive measurable improvements in medical record completeness, accuracy, and overall data quality.
  • Manage DRG & Database Inputs : Conduct timely admission reviews to assign and log accurate working Diagnosis Related Groups (DRGs).
  • Cultivate Provider Collaboration : Partner extensively with physicians and mid-level providers to resolve documentation queries prior to patient discharge.
  • Capture Care Severity : Ensure medical records precisely reflect the true severity of illness and the full level of healthcare services delivered.

What minimum requirements you'll need

Licensure / Certification / Registration:

  • One or more of the following required :
    • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
    • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
    • Clinical Documentation Prof. credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Registered Nurse credentialed from the Texas Board of Nursing obtained prior to hire date or job transfer date.
    • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.


Education:

  • High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

What additional preferences we're seeking

  • CDI experience strongly preferred
  • Second Level Review experience preferred
  • Certified Clinical Documentation Specialist (CCDS) preferred


Responsibilities

  • Optimize Clinical Documentation : Drive measurable improvements in medical record completeness, accuracy, and overall data quality.
  • Manage DRG & Database Inputs : Conduct timely admission reviews to assign and log accurate working Diagnosis Related Groups (DRGs).
  • Cultivate Provider Collaboration : Partner extensively with physicians and mid-level providers to resolve documentation queries prior to patient discharge.
  • Capture Care Severity : Ensure medical records precisely reflect the true severity of illness and the full level of healthcare services delivered.


Qualifications

Licensure / Certification / Registration:

  • One or more of the following required :
    • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
    • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
    • Clinical Documentation Prof. credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Registered Nurse credentialed from the Texas Board of Nursing obtained prior to hire date or job transfer date.
    • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.


Education:

  • High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

About Ascension

Ascension is a healthcare company that provides a range of services, including hospital care, primary care, and specialty care. The company operates more than 150 hospitals and 50 senior living facilities across the United States. Ascension also offers health insurance and other healthcare-related services. The company was founded in 1999 and is headquartered in St. Louis, Missouri.
Learn more about Ascension
Size
165,000 employees
Industry
Founded
1999

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