Clinical Documentation and Compliance Specialist

Presbyterian Healthcare Services; Albuquerque (NM); Remote; USD 60,000 - 80,000; Full time

Job summary

Presbyterian Healthcare Services is seeking a Clinical Documentation Specialist to enhance clinical documentation accuracy and compliance. This role involves daily reviews of physician documentation, collaboration with medical staff, and ensuring regulatory compliance. The ideal candidate will possess strong communication skills and a solid understanding of clinical documentation guidelines.

Benefits

Wide range of benefits including medical, vision, and dental

Paid time off

Retirement plans

Qualifications

• Strong understanding of clinical documentation and regulatory guidelines.
• Ability to work independently and prioritize tasks effectively.
• Experience handling documentation challenges and ensuring compliance.

Responsibilities

• Review physician documentation daily for accuracy and completeness.
• Track patient diagnoses and procedures to ensure appropriate service levels are documented.
• Communicate effectively with medical staff, resolving any concerns about documentation needs.

Skills

Communication

Collaboration

Detail-oriented

Education

Associates degree in Nursing

Bachelors degree with 2 yrs CDI experience

Tools

Database management

Spreadsheet software

Word processing

Job description

Clinical Documentation and Compliance Specialist

Requisition ID

2025-47556

Category

Coding/Abstracting

Location : Name

Remote Presbyterian Hospital

Location : City

Albuquerque

Location : State/Province

NM

Minimum Offer

USD $29.13/Hr.

Maximum Offer for this position is up to

USD $44.49/Hr.

Overview

Now Hiring: Clinical Documentation Specialist!

Presbyterian is seeking for a Clinical Documentation Specialist. This position requires a proactive individual with the confidence to address documentation concerns while maintaining positive relationships with medical staff. If you're ready to make a meaningful impact in clinical documentation, we'd love to hear from you!

We are seeking a detail-oriented Clinical Documentation Specialist to assist medical staff providers with accurate documentation in the medical record. This role involves daily review of physician documentation, tracking patient diagnoses and procedures, and ensuring that the level of service provided is accurately reflected.

Key Responsibilities:

Review physician documentation daily for accuracy and completeness.

• Track patient diagnoses and procedures to ensure appropriate service levels are documented.

• Work closely with physicians and staff to verify that clinical information is accurately captured.

• Address clinical documentation issues with confidence, ensuring compliance with regulatory requirements.

• Communicate effectively with medical staff, resolving any concerns about documentation needs.

• Maintain professionalism and tact while obtaining medical staff cooperation.

Qualifications:

• Strong understanding of clinical documentation and regulatory guidelines.

• Excellent communication and collaboration skills.

• Ability to work independently and prioritize tasks effectively.

• Experience handling documentation challenges and ensuring compliance.

• Team player with a flexible approach to workload management.

Why Join Us

• Full Time - Exempt: Yes
• Job is based at Presbyterian Hospital
• Remote work from home: this job is intended to be conducting in the state of New Mexico.
• Work hours: Weekday Schedule Monday-Friday
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Ideal Candidate:

The ideal candidate will work independently, managing and prioritizing their workload to ensure all tasks are completed efficiently. Flexibility is essential to assist with coverage needs, and collaboration with other reviewers and HIM coders is expected.

Qualifications

• Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required.
• Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS).
• Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required.
• Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.
• Experience with database, spreadsheet and word process required.
• Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential.
• Education specialization: Nursing

Responsibilities

• Responsible for clinical documentation analysis of the medical record, documentation completeness, coding accuracy and compliance in either electronic or hard copy form as designated.
• Performs concurrent reviews of the medical record for inpatient admissions to include assignments of DRG, identifying complication and co-morbid conditions and specific co-existing conditions and documents findings.
• Works collaboratively with the Medical Staff, Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect services provided and present an accurate hospital and physicians profile.
• Assist physicians with documentation requirements to support medical necessity for hospital and physician billing.
• Interprets clinical information in the medical record, ordered interventions, lab and test results, etc., and queries if necessary, for supporting documentation in progress notes, consultations, history and physicals, etc., as appropriate.
• Initiates communication to physicians, providers, verbally or utilizing the appropriate prompter/query tools, in order to obtain more specific principal diagnosis or co morbidities and complications. Solicit clarification of existing documentation in the medical record that support patient severity of illness.
• Acts as expert clinical resource for the HIM Coding team, working collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided.
• Coordinates with the HIM Coding team related to coding guideline requirements for clinical documentation.
• Collaborates with the HIM Coding team to provide information and education as necessary to physician and other providers not responding to prompters/ queries on documentation requirements.
• Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-10, CPT, HCPCS and APC updates and changes. This includes but is not limited to CMS, JCAHO, Nursing Standards of Practice, etc.
• Maintains up-to-date working knowledge of all PHS coding and documentation IT applications.
• Maintains current knowledge of Nursing Practice through seminars, workshops, publications, etc.
• Conducts training classes in areas of coding, documentation and compliance for physicians and other providers. This includes preparation of training materials, educational audits and answering situational questions.
• Serves as a liaison to other departments, providing clinical expertise and consultation.
• Utilizes monitoring tools to track defined measures for progress of documentation accuracy

Benefits

We offer more than the standard benefits!

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!

Learn more about our employee benefits:

https://www.phs.org/careers/why-work-with-us/benefits

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Presbyterian Healthcare Services

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1,600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

About Our Regional Delivery System

Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico

New Mexico continues to grow steadily in population and features a low cost-of living.

Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Maximum Offer for this position is up to

USD $44.49/Hr.

Compensation Disclaimer

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.

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