Clinical Documentation Specialist - RN (PRN / Remote)

At St. Tammany Health System, delivering world-class healthcare close to home is our goal. We are committed to attracting and retaining the very best professionals for every position in our health system. The health system is nestled in the heart of Covington on the north shore of Lake Pontchartrain—a peaceful, scenic, community-oriented area with an abundance of amenities to suit every taste.

About the Role

The Clinical Documentation Specialist (CDS) facilitates improved integrity of medical record documentation through interaction with healthcare providers to support the appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care. The CDS performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure an accurate depiction of patient complexity, supporting the facility’s Risk Adjustment strategy. They utilize clinical/nursing knowledge and demonstrate an understanding of complications, comorbidities, severity of illness (SOI), risk of mortality (ROM), case mix, current CMS coding guidelines, the impact of procedures on the final Diagnosis Related Group (DRG), compliant documentation for Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity. The CDS collaborates with physicians and advanced practice providers to communicate opportunities and educate the patient care team on documentation guidelines, coding requirements, and service-line specific needs.

Responsibilities

• Facilitate improved integrity of medical record documentation through provider interaction.
• Perform pre-visit and retrospective reviews of ambulatory clinical documentation.
• Ensure accurate depiction of patient complexity to support Risk Adjustment strategy.
• Apply clinical/nursing knowledge to assess complications, comorbidities, SOI, ROM, case mix, and CMS coding guidelines.
• Support compliant documentation for HCC, ICD-10-CM accuracy, and medical necessity.
• Collaborate with physicians and advanced practice providers to educate on documentation and coding requirements.

Requirements

• Graduate of an accredited School of Nursing and current Louisiana Registered Nurse License.
• Five (5) years of clinical experience in an acute or ambulatory care setting.
• Knowledge of ICD-10 coding principles and Risk Adjustment Coding.
• Proficiency in Microsoft Office (PowerPoint, Excel, Word), 3M software, and Encoder experience.
• Excellent written and verbal communication, critical thinking, and interpersonal skills.
• Broad clinical experience in an outpatient setting with knowledge of complex disease processes.
• Ability to work independently with minimal supervision and strong self-motivation.
• Proficient organizational and planning skills.

Preferred Qualifications

• Bachelor of Science degree in Nursing.
• Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, and auditing.
• Current Certified Clinical Documentation Specialist (CCDS) through the Association for Clinical Documentation Improvement Specialists (ACDIS).

Physical Demands

• Must possess good physical health.
• Requires standing, sitting, or walking for long periods of time.
• Lifting at least 20 pounds is required.
• Must be able to work with a moderate level of noise.

Physical effort required:

• Constant (67%-100%): Seeing
• Frequently (34%-66%): Handling/feeling, talking, hearing
• Occasionally (1%-33%): Lifting, carrying, pushing/pulling, stooping, crouching, reaching

Schedule

Monday through Friday, 8:00 AM – 4:30 PM.