Community Health Systems

Operates acute care hospitals nationwide

Clinical Documentation Specialist

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeRemote in USANo salary listedRemote

About the Job

Requirements

An Associate Degree in Nursing or comparable clinical field, such as an International MD, is required.
Three to five years of acute care hospital nursing experience, such as on a medical/surgical unit or intensive care unit, is required.
A current RN state or compact-state license, or comparable clinical license such as an International MD, is required.
Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics is required.
Proficiency in clinical documentation improvement and medical-record software systems, such as 3M 360 Encompass and Iodine Interact, is required.
Ability to develop and deliver educational programs tailored to clinical and administrative audiences is required.
Commitment to maintaining compliance with regulatory standards and corporate policies is required.

Responsibilities

Analyze inpatient clinical records to identify opportunities to improve documentation accuracy and ensure assigned codes reflect patient severity and acuity.
Follow corporate-recommended clinical documentation improvement workflows and use clinical documentation improvement and medical-record software to support documentation practices.
Use approved physician query processes to clarify documentation, ensure queries are compliant, necessary, and non-leading, and follow up daily on unanswered queries.
Conduct follow-up reviews of patient records to identify new documentation opportunities and ensure accuracy through continuous review.
Track clinical documentation improvement activities in the software, accurately report impact metrics, and maintain records of interactions and documentation efforts.
Educate and train providers about documentation improvement recommendations through individual or group sessions.
Collaborate with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
Lead physician education initiatives, develop facility-level strategies to improve documentation practices, and conduct formal training sessions.
Monitor regulatory changes in coding, documentation, and quality metrics, ensure compliance with updated standards, and share information with staff as needed.
Create and submit accurate reports in a timely manner and maintain current knowledge of best practices and industry standards to support clinical documentation improvement goals.
Maintain regular and reliable attendance and comply with all policies and standards.

Desired Qualifications

A bachelor's degree in Nursing, Health Information Management, or a related field is preferred.
Three to five years of experience in clinical documentation improvement, health information management, or inpatient coding is preferred.
Experience in physician education or query processes is preferred.
Familiarity with regulatory standards and quality metrics related to clinical documentation is preferred.
CCS (Certified Coding Specialist), ICD-10 certification, or trainer designation is preferred.
Certified Clinical Documentation Specialist (CCDS) is preferred.
RHIT (Registered Health Information Technician) is preferred.
RHIA (Registered Health Information Administrator) is preferred.
CDIP (Clinical Documentation Improvement Professional) is preferred.
Certified Coder-AHIMA or AAPC is preferred.

Job Summary

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.

Qualifications

Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required
Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
3-5 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) 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

Knowledge, Skills and Abilities

Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact).
Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
Commitment to maintaining compliance with regulatory standards and corporate policies.

Licenses and Certifications

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

About the Company

Community Health Systems

Operates acute care hospitals nationwide

Community Health Systems operates general acute care hospitals across 14 states, owning or leasing 71 facilities to deliver healthcare outside urban centers. Its main business is running hospital networks and providing medical and surgical services to patients, funded by payments from patients, insurers, and government programs like Medicare and Medicaid. The company also offers management services to its affiliates through a professional services corporation. Its workflow centers on developing and operating healthcare delivery systems, supporting a wide range of needs from emergency care to specialized treatments. The goal is to help people get well and live healthier by providing accessible non-urban and suburban hospital-based care while navigating a regulated, competitive US healthcare market.

Company size: 5,001-10,000
Company stage: IPO
Headquarters: Franklin, TN
Founded: 1985

Recently Posted Jobs

Explore more opportunities at Community Health Systems

See more jobs