LTACH CDS: Remote-Ready Clinical Documentation Expert

Vibra Healthcare; Abilene, Wylie (TX, TX); Hybrid; USD 75,000 - 95,000; Full time

Job summary

Vibra Healthcare is seeking a Clinical Documentation Specialist (CDS) for LTACHs in Texas. The role focuses on evaluating inpatient records to reflect severity of illness, ROM, and resource use.

Collaboration with physicians and coding staff is essential to bridge clinical findings and compliant documentation. Ideal candidates have nursing or HIM qualifications, 3–5 years in a related field, and proficiency with major EHR systems.

Qualifications

• RN license or RHIA/RHIT required or in progress.
• BSN preferred or Health Information Management program completed.
• 3–5 years acute care nursing or CDS/coding experience.

Responsibilities

• Perform daily concurrent reviews of inpatient records for LTACH beds.
• Audit admission notes, progress notes, procedure reports, diagnostics, and discharge summaries.
• Identify secondary diagnoses, comorbidities, or complications and ensure accurate documentation.

Skills

RN license

RHIA/RHIT

CCDS/CDIP

ICD-10-CM

MS-DRG / MS-LTC-DRG

CMS guidelines

EHR proficiency

communication skills

Education

BSN

HIM program

Tools

Epic

Cerner

Meditech

Job description

Vibra Healthcare is seeking a Clinical Documentation Specialist (CDS) for LTACHs in Texas. The role focuses on evaluating inpatient records to reflect severity of illness, ROM, and resource use.

Collaboration with physicians and coding staff is essential to bridge clinical findings and compliant documentation. Ideal candidates have nursing or HIM qualifications, 3–5 years in a related field, and proficiency with major EHR systems.