RN-Clinical Documentation Specialist

Company: SSM Health
Location: Saint Charles
Posted on: September 5, 2021

Job Description:

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.

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

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.

Keywords: SSM Health, Saint Charles , RN-Clinical Documentation Specialist, Other , Saint Charles, Missouri