Hybrid CDI Specialist - Elevate Patient Documentation

Community Health Systems, Inc.; Las Cruces (NM); Hybrid; USD 60,000 - 90,000; Full time

Job summary

Community Health Systems, Inc. is seeking a Clinical Documentation Specialist (CDS) for a hybrid position at Mountain View Medical Center.

The CDS will perform CDI activities to improve accuracy, quality, and completeness of patient records, ensuring codes reflect clinical status and care provided. The role involves collaboration with providers, physician queries, education, and ongoing monitoring of regulatory standards and quality metrics to support compliant documentation and optimal patient

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 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

Responsibilities

• 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

Skills

CDI principles

Inpatient coding

Quality metrics

CDI software

Communication skills

Educational programs

Organizational skills

Regulatory compliance

Education

Associate degree in nursing

Bachelor's degree in nursing

Health Information Management

Related field

Tools

3M 360 Encompass

Iodine Interact

Job description

Community Health Systems, Inc. is seeking a Clinical Documentation Specialist (CDS) for a hybrid position at Mountain View Medical Center.

The CDS will perform CDI activities to improve accuracy, quality, and completeness of patient records, ensuring codes reflect clinical status and care provided. The role involves collaboration with providers, physician queries, education, and ongoing monitoring of regulatory standards and quality metrics to support compliant documentation and optimal patient