Inpatient Clinical Documentation Specialist II

BBSS Beyond Blue; Kentucky; Hybrid; USD 60,000 - 85,000; Full time

Job summary

University of Kentucky is seeking an Inpatient Clinical Documentation Specialist II to ensure accuracy, quality, and completeness of clinical documentation for patient care, regulatory compliance, and reimbursement. You will collaborate with providers, coders, case managers, and the healthcare team to validate severity of illness, risk of mortality, and medical necessity.

The role involves chart reviews, data reporting, and presenting findings to leadership, with a focus on continuous

Qualifications

• Responsible for ensuring accuracy, quality, and completeness of clinical documentation to support patient care, regulatory compliance, and appropriate reimbursement.
• Collaborates with providers, coders, case managers, and the healthcare team to validate severity of illness, risk of mortality, and medical necessity.
• Conducts comprehensive chart reviews and clarifies provider documentation to improve clinical accuracy and data integrity.
• Coordinates reporting, trending, and analysis to support organizational quality initiatives and documentation integrity goals.

Responsibilities

• Performs admission and continued stay reviews to validate principal diagnosis, comorbidities, and clinical indicators supporting severity of illness.
• Conducts follow-up reviews to confirm provider responses and integration of documentation into the medical record.
• Partners with coding specialists to resolve documentation and data discrepancies that impact coding accuracy and reimbursement.
• Develops and maintains data reports, spreadsheets, and dashboards to track trends and outcomes related to documentation integrity.
• Prepares summaries and presentations of review findings and documentation performance for leadership and hospital committees.
• Supports continuous improvement initiatives by identifying gaps in documentation and recommending process enhancements.
• Maintains current knowledge of coding, CDI practices, and regulatory changes to guide accurate documentation review.
• Performs other duties as assigned.

Education

Associate’s degree

Job description

Beyond Blue Job Posting Title: Inpatient Clinical Documentation Specialist II Requisition Number: R-000003831 Department Name: Supervisor, Inpatient Clinical Documentation Work Location: Remote-KY Grade Level: 11 Type of Position: Regular Position Time Status: Full time Equivalency Link https://hr.uky.edu/employment/working-uk/equivalencies Shift: Days (United States of America)

Job Summary

Responsible for ensuring accuracy, quality, and completeness of clinical documentation to support patient care, regulatory compliance, and appropriate reimbursement. Provides advanced expertise by collaborating with providers, coders, case managers, and the healthcare team to validate severity of illness, risk of mortality, and medical necessity. Conducts comprehensive chart reviews and clarifies provider documentation to improve clinical accuracy and data integrity. Coordinates reporting, trending, and analysis to support organizational quality initiatives and documentation integrity goals.

Essential Functions

• Performs admission and continued stay reviews to validate principal diagnosis, comorbidities, and clinical indicators supporting severity of illness.
• Conducts follow-up reviews to confirm provider responses and integration of documentation into the medical record.
• Partners with coding specialists to resolve documentation and data discrepancies that impact coding accuracy and reimbursement.
• Develops and maintains data reports, spreadsheets, and dashboards to track trends and outcomes related to documentation integrity.
• Prepares summaries and presentations of review findings and documentation performance for leadership and hospital committees.
• Supports continuous improvement initiatives by identifying gaps in documentation and recommending process enhancements.
• Maintains current knowledge of coding, CDI practices, and regulatory changes to guide accurate documentation review.
• Performs other duties as assigned.

Education Requirement

Associate’s degree

Nursing Experience Requirement

2+ years of related experience

An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated based on hours worked per week. Volunteer work and internships for academic credit are not counted.

Certifications & Licensures

Registered Nurse

Working Conditions

• A. Lifting, pushing, and/or pulling objects up to 50lbs:2.
• B. Lifting, pushing, and/or pulling objects over 50lbs:1.
• C. Standing or walking with objects up to 10lbs:3. Intermittent (10% - 50% of the time)
• D. Standing or walking with objects up to 25lbs:2. Occasional (< 10% of the time)
• E. Sitting at the computer workstation for extended periods:3. Intermittent (10% - 50% of the time)
• F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials:2. Occasional (< 10% of the time)
• G. Repetitive motion:3. Intermittent (10% - 50% of the time)
• H. Working at heights above 4 feet:1. Never
• I. Working in confined spaces:1. Never
• J. Risk of injuries from use of equipment on the job:2. Occasional (< 10% of the time)
• K. Job-related travel:2. Occasional (< 10% of the time)
• L. Loud noises:1. Never
• M. Temperature extremes:1. Never
• N. Hazardous chemicals and fumes including waste:2. Occasional (< 10% of the time)
• O. Radiation:1. Never
• P. Burns:1. Never
• Q. Cuts/Punctures:2. Occasional (< 10% of the time)
• R. Bloodborne/airborne pathogens:2. Occasional (< 10% of the time)
• S. Recombinant DNA or viral vectors:1. Never
• T. Combative/violent people:1. Never
• U. Animal handling (including carcasses):1. Never
• V. Please specify other(s) and amount of exposure (i.e. Occasional, Intermittent or Regular): N/A

Physical Demands

This position requires intermittent sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); intermittent standing or walking with objects weighing up to 10 pounds; occasional standing or walking with objects weighing up to 25 pounds; and occasional lifting, pushing, or pulling objects weighing up to 50 pounds.

Our University Community

We value the well-being of each of our employees and are dedicated to creating a healthy place for everyone to work, learn and live. In the interest of maintaining a safe and healthy environment for our students, employees, patients and visitors, the University of Kentucky is a Tobacco & Drug Free campus. The University follows both the federal and state Constitutions as well as all applicable federal and state laws on nondiscrimination. The University provides equal opportunities for qualified persons in all aspects of institutional operations and does not discriminate on the basis of race, color, national origin, ethnic origin, religion, creed, age, physical or mental disability, veteran status, uniformed service, political belief, sex, sexual orientation, gender identity, gender expression, pregnancy, marital status, genetic information or social or economic status. Any candidate offered a position may be required to pass pre-employment screenings as mandated by University of Kentucky Human Resources. These screenings may include a national background check and/or drug screen. Our growth is creating opportunities! Our team is expanding, and we want to hire the most talented people we can. Continued success depends on it! Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful.