Clinical Documentation Specialist

Community Health Systems; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Community Health Systems is seeking a Clinical Documentation Specialist (CDS) to support CDI activities, ensuring accurate diagnoses and procedures reflected in patient records. You will educate providers, query physicians when needed, and collaborate with coding teams to improve documentation quality across facilities.

The role emphasizes adherence to regulatory standards, continuous improvement, and timely reporting of CDI impact metrics to support quality metrics and patient care.

Qualifications

• Associate Degree in Nursing or comparable clinical field (e.g., International MD) required
• Bachelor's Degree in Nursing, Health Information Management, or related field preferred
• 3-5 years of acute care hospital nursing experience required
• 3-5 years of CDI/health information management or inpatient coding preferred
• Experience in physician education or query processes preferred
• Familiarity with regulatory standards and quality metrics related to clinical documentation preferred

Responsibilities

• Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy.
• Follows CDI workflows and uses CDI software to support documentation practices.
• Uses physician query processes to clarify documentation and follows up on unanswered queries.
• Performs follow-up reviews to identify new documentation opportunities and maintain accuracy.
• Tracks CDI activities and reports impact metrics.
• Provides education and training to providers on documentation improvements.
• Collaborates with coding professionals to ensure accurate data and compliant documentation.
• Leads physician education initiatives and develops strategies to improve documentation practices.
• Monitors regulatory changes in coding and quality metrics and shares updates with staff.

Skills

Clinical documentation improvement

Analytical skills

Communication skills

Regulatory knowledge

Documentation software

Education delivery

Organizational skills

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing

Health Information Management degree

Tools

3M 360 Encompass

Iodine Interact

Job description

Job Summary

The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.

Essential Functions

• Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
• Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices.
• Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
• Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
• Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
• Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
• Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
• Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
• Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
• Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required
• Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
• 3-5 years of acute care hospital nursing experience (e.g., medical/surgical unit, intensive care) required
• 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred
• Experience in physician education or query processes preferred
• Familiarity with regulatory standards and quality metrics related to clinical documentation preferred

Knowledge, Skills and Abilities

• Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
• Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
• Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact).
• Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
• Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
• Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
• Commitment to maintaining compliance with regulatory standards and corporate policies.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required
• CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
• Certified Clinical Documentation Specialist (CCDS) preferred
• RHIT - Registered Health Information Technician preferred or
• RHIA - Registered Health Information Administrator preferred
• CDIP - Clinical Documentation Improvement Professional preferred or
• Certified Coder-AHIMA or AAPC preferred