On-Site CDI Specialist - Shape Patient Records

CHS Corporate; Missouri; On-site; USD 65,000 - 90,000; Full time

Job summary

Poplar Bluff Medical Center is seeking a Clinical Documentation Specialist (CDS) to lead CDI activities, improve documentation accuracy, and ensure codes reflect patient illness and care provided. The role partners with providers to educate and query physicians, supporting regulatory compliance and quality metrics.

Local to Missouri, the CDS works at the facility with on-site requirements and potential collaboration across coding and clinical teams to optimize data integrity and reporting for

Qualifications

• Associate Degree in Nursing, or comparable clinical field 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 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 codes reflect patient severity and acuity.
• Adheres to 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 knowledge

Analytical skills

Communication

Education/training

Regulatory knowledge

Education

Associate Degree in Nursing

Bachelor's degree in Nursing/Health Information Management

Tools

3M 360 Encompass

Iodine Interact

Job description

Poplar Bluff Medical Center is seeking a Clinical Documentation Specialist (CDS) to lead CDI activities, improve documentation accuracy, and ensure codes reflect patient illness and care provided. The role partners with providers to educate and query physicians, supporting regulatory compliance and quality metrics.

Local to Missouri, the CDS works at the facility with on-site requirements and potential collaboration across coding and clinical teams to optimize data integrity and reporting for