Senior Clinical Documentation Specialist

• Location: Remote

• Facility: Ascension St. John Medical Center

• Specialty: Health Information Management Operations

• Schedule: Full-time | Monday-Friday | 8am-5pm

• Lead high-complexity clinical chart reviews to capture accurate diagnosis codes and ensure patient care journeys are fully reflected in the medical record.

• Collaborate directly with physicians and advanced practice providers to clarify clinical documentation, resolving gaps to support severity of illness and risk of mortality data.

• Drive quality improvement initiatives across market teams to uphold compliance standards, improve case mix index accuracy and elevate overall documentation practices.

• Serve as a subject matter expert and mentor to guide colleagues on evolving coding guidelines, clinical indicators and CDI best practices.

Licensure / Certification / Registration

• Required Credential(s):
  • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists 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 with 1 year of experience OR 5 years of applicable cumulative job specific experience required. 2 years of leadership or management experience preferred.

Additional Preferences:

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification

• Minimum 3 years of progressive Clinical Documentation Integrity (CDI) experience in an acute care setting

• Active Registered Nurse (RN) license or Certified Coding Specialist (CCS) credential