Clinical Documentation Improvement Lead

CHS Corporate; United States; On-site; USD 75,000 - 105,000; Full time

Job summary

CHS Corporate seeks a Clinical Documentation Specialist to advance CDI activities that improve accuracy, quality, and completeness of patient records. The CDS ensures codes reflect patient status and care provided, collaborating with clinicians to educate and query when necessary.

You will analyze inpatient records, follow physician query processes, track CDI impact metrics, provide education sessions, and work with coding colleagues to ensure compliant documentation.

Qualifications

• Associate Degree in Nursing or comparable clinical field required
• Bachelor's degree preferred in Nursing, HIM, or related field
• 3–5 years of acute care nursing experience required
• 3–5 years of CDI, health information management, or inpatient coding preferred
• Experience in physician education or query processes preferred

Responsibilities

• Analyzes inpatient records to identify documentation improvement opportunities and ensures codes reflect patient severity
• Adheres to CDI workflows and uses CDI software to support documentation practices
• Uses physician query processes to clarify documentation, following up on unanswered queries
• Performs follow-up reviews to identify new opportunities and ensure accuracy
• Tracks CDI activities and reports impact metrics with clear records of interventions
• Provides education to providers and conducts training sessions
• Collaborates with coding professionals to ensure accurate diagnostic and procedural data
• Leads physician education initiatives and develops strategies to improve documentation at facility level
• Monitors regulatory changes and ensures compliance with standards
• Creates and submits accurate reports to support CDI goals
• Maintains regular attendance and complies with policies

Skills

CDI knowledge

Analytical skills

Communication

Organizational skills

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing/Health Information Management

Tools

3M 360 Encompass

Iodine Interact

Job description

CHS Corporate seeks a Clinical Documentation Specialist to advance CDI activities that improve accuracy, quality, and completeness of patient records. The CDS ensures codes reflect patient status and care provided, collaborating with clinicians to educate and query when necessary.

You will analyze inpatient records, follow physician query processes, track CDI impact metrics, provide education sessions, and work with coding colleagues to ensure compliant documentation.