Clinical Document Specialist III

Jobot; Town of Florida (NY); Hybrid; USD 110,000 - 130,000; Full time

Benefits offered by this job

Hybrid work environment

Relocation assistance

Excellent healthcare benefits

Growth opportunities

Established healthcare organization

Job summary

Jobot is seeking a Clinical Document Specialist III to lead the CDI team in a large hospital network. This remote/hybrid role requires extensive CMS and CCDS knowledge, nursing background, and experience guiding clinical documentation across ED, ICU, and post-acute units.

You will oversee audits, mentor the CDI staff, and collaborate with clinicians to ensure compliant, accurate records while supporting quality initiatives and organizational growth.

Qualifications

• Bachelor's or higher degree; RN/NP/PA licensure preferred.
• Minimum 5 years acute care nursing experience in medical/surgical, ICU, post-acute, or ED.
• At least 2 years as Clinical Documentation Specialist.
• Experience leading a CDI team in healthcare.
• CMS and CCDS guidelines knowledge essential.
• Strong leadership and collaboration with providers and admins.

Responsibilities

• Lead the CDI team to ensure high-quality documentation of clinical care.
• Develop strategies to improve accuracy, completeness, and consistency of documentation.
• Provide guidance and training on documentation standards and best practices.
• Collaborate with units (ED, surgical, ICU, post-acute) for aligned documentation.
• Conduct regular CDI audits and provide feedback to teams and providers.
• Monitor CDI quality metrics and drive corrective actions.
• Stay updated on CMS and CCDS guidelines and ensure compliance.
• Foster continuous improvement and operational efficiency within CDI.

Skills

Leadership

CMS knowledge

Clinical documentation

Communication

Team management

Education

Bachelor's degree

Job description

Clinical Document Specialist III - Remote

Salary: $110,000 - $130,000 per year

We are a large, full-service hospital organization providing a wide range of medical services including emergency care, heart and cancer treatment, maternity with a Level II NICU, and advanced surgical procedures like robot-assisted surgery.

Why join us?

• Excellent Medical, Dental, Vision
• Growth Opportunity
• Established Healthcare Organization
• Hybrid work environment
• Relocation Assistance

Job Details

We are seeking an enthusiastic and experienced Clinical Document Specialist III to join our dynamic healthcare team. This role is critical in leading the Clinical Documentation Improvement (CDI) team to ensure the accuracy, integrity, and quality of patient records. The successful candidate will have a strong understanding of various medical departments, including emergency, surgical, intensive care, and post-acute care units. The role demands a professional with a proven track record in healthcare quality management, specifically in the areas of CMS and CCDS.

Responsibilities

• 1. Lead the Clinical Documentation Improvement (CDI) team to ensure high-quality documentation of clinical care.
• 2. Develop and implement strategies to enhance the accuracy, completeness, and consistency of clinical documentation.
• 3. Provide guidance and training to the CDI team on clinical documentation standards and best practices.
• 4. Collaborate with medical, surgical, intensive care, and post-acute care units to ensure alignment of documentation practices.
• 5. Conduct regular audits of clinical documentation and provide feedback to the CDI team and healthcare providers.
• 6. Monitor and report on CDI quality metrics, identifying areas for improvement and implementing corrective actions.
• 7. Stay updated on CMS and CCDS guidelines and ensure compliance within the organization.
• 8. Foster a culture of continuous improvement, encouraging innovation and efficiency within the CDI team.

Qualifications

• 1. A bachelor's or higher educational degree. An advanced degree will be an added advantage.
• 2. Minimum of 5 years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience
• 3. A minimum of 2 years of experience of Clinical Documentation Specialist experience.
• 4. RN, NP, or PA licensure
• 5. Demonstrated experience in leading a CDI team in a healthcare setting.
• 6. Extensive knowledge of CMS and CCDS guidelines.
• 7. Strong leadership and team management skills, with the ability to motivate and guide a team towards achieving high-quality outcomes.
• 8. Excellent communication and interpersonal skills, with the ability to collaborate effectively with healthcare providers and administrators.
• 9. Proficiency in using healthcare information systems and software.
• 10. Certification in Clinical Documentation Improvement (CCDI) or equivalent is desirable.

Jobot is an Equal Opportunity Employer. We provide an inclusive work environment that celebrates diversity and all qualified candidates receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, age (40 and over), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. Jobot also prohibits harassment of applicants or employees based on any of these protected categories. It is Jobot’s policy to comply with all applicable federal, state and local laws respecting consideration of unemployment status in making hiring decisions.

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