Clinical Documentation Specialist & CDI Educator

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

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.