Clinical Documentation Specialist - RN (Remote)

About the role

At St. Tammany Health System, delivering world-class healthcare close to home is our goal. The health system is nestled in the heart of Covington on the north shore of Lake Pontchartrain, a peaceful, scenic, community‑oriented area with abundant amenities.

Responsibilities

• Facilitate improved integrity of medical record documentation through interaction with healthcare providers to support appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care.
• Perform pre‑visit and retrospective reviews of ambulatory clinical documentation as part of a multidisciplinary team to ensure accurate depiction of patient complexity for Risk Adjustment strategy.
• Utilize clinical/nursing knowledge and understanding of complications, comorbidities, SOI, ROM, case mix, CMS coding guidelines, impact of procedures on final DRG, compliant documentation for HCC capture, ICD‑10‑CM accuracy and specificity, and medical necessity.
• Collaborate with physicians and advanced practice providers to communicate documentation opportunities and educate the patient care team on guidelines, coding requirements, and service‑line specific requirements.

Minimum Qualifications

• 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 guidelines and Risk Adjustment Coding.
• Proficiency in Microsoft Office applications (PowerPoint, Excel, Word), 3M software, and Encoder experience.
• Excellent written and verbal communication skills, critical thinking skills, and interpersonal skills.
• Knowledge of complex disease processes with broad clinical experience in an outpatient setting.
• Ability to work independently with minimal supervision, self‑motivated.
• Proficient organizational and planning skills.
• Must possess good physical health; able to stand, sit, or walk for long periods; lift at least 20 pounds; work with a moderate noise level.

Preferred Qualifications

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

Schedule

Scheduled Weekly Hours: 40; Work Shift: 7:30 AM – 4:00 PM (Monday – Friday).