Clinical Documentation Specialist

Carson Tahoe Health; Carson City (NV); On-site; USD 75,000 - 105,000; Full time

Job summary

Carson Tahoe Health in Carson City, NV seeks a Clinical Documentation Specialist to improve hospital documentation quality and ensure accurate MS-DRG assignments. You will collaborate with physicians, nursing staff, and HIM professionals to maintain complete clinical records.

The role requires inpatient coding experience, professional certifications in coding, and strong communication to educate providers. You will support CMS guidelines and participate in CDI initiatives with the care team.

Qualifications

• Minimum 5 years of coding experience with at least 3 years in inpatient coding.
• Active AHIMA/AAPC certifications or RN license with acute care nursing experience.
• Experience with CDI processes and CMS guidelines preferred.

Responsibilities

• Promote accurate, complete, and timely clinical documentation.
• Identify clinical indicators to support ICD-10 and MS-DRG assignments.
• Query clinical staff when documentation lacks specificity or clarity.

Skills

Interdisciplinary collaboration

Attention to detail

Communication with providers

Regulatory knowledge

Education

AHIMA RHIA

AHIMA RHIT

AHIMA CCS

AAPC CIC

AHIMA CDIP/ACDIS CCDS

RN license with acute care

Bachelor's degree in health field

Tools

EHR systems

Job description

• The Clinical Documentation Specialist works concurrently with the interdisciplinary team to improve the overall quality and completeness of clinical documentation in the patients’ medical record. Facilitates appropriate inpatient and long term acute care clinical documentation thought extensive interaction with provider, nursing staff, other patient caregivers, and health information management professionals. Ensures that documentation reflects the level of services rendered to all patients who are MS-DRG payers. Ensures the accuracy and completeness of clinical information used for measuring and reporting providers and medical center outcomes to various reporting agencies.

Essential Functions

• Promotes accurate, complete, and timely clinical documentation by conducting regular evaluations of documentation in accordance with CDI procedure
• Identifies clinical indicators to ensure complete provider documentation needed to support the assignment of ICD-10 diagnosis codes, procedure codes, MS_DRG, present on admission indicators, severity of illness and risk of mortality.
• Collaborates with Medical staff to convey written and/or verbal queries to clinical staff when documentation inaccuracies arise due to illegibility, missing/conflicting information, or further specificity is required. In support of the major diagnostic categories.
• Submits concurrent or retrospective queries in accordance with the urgency of the submission
• Tracks the status of all queries submitted to clinical staff through oversight and maintenance of CDI EHR tools.
• Evaluate CDI processes by running analytic assessments, evaluating efficiency, and identifying possible process improvements. Including educational opportunities for documentation trends to all member of the healthcare team.
• Adheres to protocols established by CDI, HIM and revenue cycle to ensure productivity standards are met and the integrity of health records is upheld
• Executes excellent customer service and professionalism when interacting with providers, and other coworkers.
• Maintains current knowledge of medical documentation regulations and guidelines by independently following industry trends, and provides guidance on requirements set forth by Centers for Medicare & Medicaid Services (CMS), other third‑party payers, and all other applicable sources
• Assist with special projects as needed and performs related duties as assigned. Ability to multi‑task with prioritization.

Qualifications

• Required
• 5 years of coding experience, with at least 3 years of inpatient coding. To include active certificate below.
• AHIMA RHIA
• AHIMA RHIT
• AHIMA CCS
• AAPC CIC
• Or active RN license with at least 2 years’ acute care nursing experience
• Preferred
• Bachelor’s degree in health field or equivalent professional experience.
• AHIMA CDIP or ACDIS CCDS certification
• EHR experience

Top 5 Reasons to Live in Carson City, Nevada

• Live, work and play in one of the most beautiful regions in the world
• Enjoy an array of outdoor activities world class skiing, golf, camping, mountain biking, hiking, water skiing, kayaking, hunting and fishing
• Just next door is Beautiful Lake Tahoe
• We are minutes from Reno known as the 'biggest little city in the world' - Fine dining, nightlife, shopping and home to the University of Nevada Reno.
• Family friendly atmosphere with affordable housing & excellent school system
• No State Income Tax
• Paid Time Off, Mental Health, and Volunteer Days
• 100% Vested 401K & Roth with Company Contribution
• Tuition Reimbursement
• On Site Education & Certification Programs
• Base Wage Increases for Relevant Advanced Degrees
• Free Calm App Subscription

About Carson Tahoe Health

CTH is a not-for-profit healthcare system with 240 licensed acute care beds, fully accredited by the Center for Improvement in Healthcare Quality (CIHQ). CTH was voted 5th most beautiful hospital in the nation nestled among the foothills of the Sierra Nevada in North Carson City and only a short drive away from world-famous Lake Tahoe & Reno. We serve a population of over 250,000 and feature two hospitals, two urgent cares, an emergent care center, outpatient services and a provider network with 19 regional locations.