Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.

Essential Functions

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.

RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required

CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or

Certified Clinical Documentation Specialist (CCDS) preferred

RHIT - Registered Health Information Technician preferred or

RHIA - Registered Health Information Administrator preferred

CDIP - Clinical Documentation Improvement Professional preferred or

Certified Coder-AHIMA or AAPC preferred