Inpatient CDI Specialist - Elevate Documentation & Coding

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

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.