Clinical Documentation Specialist

Clinical Documentation Specialist

Requirements

• Associate Degree in Nursing, Health Information Management, or a related field required
• 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required
• RN – Registered Nurse – State Licensure and/or Compact State Licensure required
• CCS-Certified Coding Specialist or ICD-10 certification or trainer designation required
• Certified Clinical Documentation Specialist (CCDS) required

Responsibilities

• Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
• Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices.
• Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
• Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
• Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
• Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
• Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
• Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
• Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
• Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
• Performs other duties as assigned.
• Complies with all policies and standards.

Preferred Qualifications

• Bachelor’s Degree in Nursing, Health Information Management, or a related field preferred
• 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred
• Experience in physician education or query processes preferred
• Familiarity with regulatory standards and quality metrics related to clinical documentation preferred
• RHIT – Registered Health Information Technician preferred
• RHIA – Registered Health Information Administrator preferred
• CDIP – Clinical Documentation Improvement Professional preferred
• Certified Coder-AHIMA or AAPC preferred