Clinical Documentation Improvement Specialist (CDS) - CHC

Vibra Travels; Abilene, Wylie (TX, TX); Hybrid; USD 75,000 - 95,000; Full time

Job summary

Vibra Healthcare is seeking a Clinical Documentation Specialist (CDS) for LTACHs in Texas. The role focuses on evaluating inpatient records to reflect severity of illness, ROM, and resource use.

Collaboration with physicians and coding staff is essential to bridge clinical findings and compliant documentation. Ideal candidates have nursing or HIM qualifications, 3–5 years in a related field, and proficiency with major EHR systems.

Qualifications

• RN license or RHIA/RHIT required or in progress.
• BSN preferred or Health Information Management program completed.
• 3–5 years acute care nursing or CDS/coding experience.

Responsibilities

• Perform daily concurrent reviews of inpatient records for LTACH beds.
• Audit admission notes, progress notes, procedure reports, diagnostics, and discharge summaries.
• Identify secondary diagnoses, comorbidities, or complications and ensure accurate documentation.

Skills

RN license

RHIA/RHIT

CCDS/CDIP

ICD-10-CM

MS-DRG / MS-LTC-DRG

CMS guidelines

EHR proficiency

communication skills

Education

BSN

HIM program

Tools

Epic

Cerner

Meditech

Job description

Facility Type

Long Term Acute Care

Overview

The Clinical Documentation Specialist (CDS) - LTACH evaluates patient medical records to ensure clinical documentation accurately reflects the complexity of care, severity of illness (SOI), risk of mortality (ROM), and resource utilization specific to long-term acute care patients. Operating in an environment focused on complex, extended-stay medical cases - such as prolonged mechanical ventilation, severe wound care, and multi-organ failure, the CDS collaborates directly with physicians, interdisciplinary care teams, and coders to bridge clinical findings and compliant documentation.

Responsibilities

Primary Responsibilities

• Conduct daily concurrent reviews of inpatient medical records for assigned LTACH beds.
• Audit admission notes, progress notes, procedure reports, diagnostic findings, and discharge summaries for accuracy, completeness, and specificity.
• Monitor for clinical indicators of secondary diagnoses, comorbidities, or complications (e.g., acute respiratory failure, severe sepsis, Stage III/IV pressure injuries, protein-calorie malnutrition).

Provider Collaboration & Query Process

• Initiate compliant written or verbal queries to attending physicians, pulmonologists, and specialists when documentation is vague, ambiguous, or lacks clinical validation.
• Ensure all queries follow AHIMA, ACDIS, and CMS compliant query guidelines (non-leading).
• Conduct follow-up record reviews after queries are placed to verify appropriate provider responses in the Electronic Health Record (EHR).

LTACH Regulatory & Quality Compliance

• Ensure documentation meets LTACH Prospective Payment System (MS-LTC-DRG) criteria, including qualifying length-of-stay thresholds and primary LTACH diagnostic criteria.
• Support the accurate capture of Quality Reporting Program (QRP) data, post-acute care quality measures, and patient risk adjustment data.
• Participate in pre-bill chart audits to reduce billing delays, avoid improper payment denials, and optimize compliant reimbursement.

Staff Education & Support

• Provide continuous coaching and formal education to physicians, mid-level providers, and clinical staff on documentation requirements, Medicare guidelines, and coding specificity.
• Serve as a liaison between the clinical nursing/medical staff and the HIM coding team.

Qualifications

Key Requirements & Qualifications

• Education: Graduate of an accredited School of Nursing (BSN preferred) or Health Information Management program.
• Licensure / Certification:
  • Active Registered Nurse (RN) license, OR RHIA / RHIT certification.
  • Preferred: Certified Clinical Documentation Specialist (CCDS) or Certified Document Integrity Specialist (CDIP) credential.
• Experience:
  • Minimum of 3-5 years of acute care clinical nursing experience (ICU, Step-Down, Telemetry, or Med-Surg) or CDS/coding experience.
  • Prior LTACH, rehabilitation, or post-acute care documentation experience preferred.
• Skills & Knowledge:
  • Deep clinical understanding of complex disease processes, diagnostic criteria, and pharmacology.
  • Strong knowledge of ICD-10-CM coding conventions, MS-DRG / MS-LTC-DRG assignment, and CMS guidelines.
  • Proficiency with Electronic Health Record (EHR) systems (e.g., Epic, Cerner, Meditech) and CDI tracking software.
  • Excellent verbal and written communication skills to effectively collaborate with medical staff.
• Working Conditions:
  • Environment: On-site hospital environment with hybrid remote options depending on facility structure.
  • Physical Demands: Prolonged periods of sitting, viewing computer screens, and performing detailed chart reviews.