Clinical Documentation Improvement Specialist

All Locations — Louisiana, Texas, Mississippi, Tennessee, United States

The Quality Improvement department has an immediate full-time Clinical Documentation Improvement Specialist position open. The position reports directly to the Director of Quality Improvement.

The Clinical Documentation Improvement Specialist builds and runs the company's documentation education program. The purpose of the program is accuracy: the patient care record must reflect the patient's condition and the care actually provided. Audit findings, medic returns, and denial data show where records fall short of that standard, and this position turns those findings into training and education for field personnel across Louisiana, Texas, Mississippi, and Tennessee. The position emphasizes teaching, clear written feedback, EPCR expertise, and measurable improvement in documentation quality.

DUTIES AND RESPONSIBILITIES:

• Curriculum: Build the documentation curriculum: standards, protocol-aligned reference materials, in-services, and on-demand modules for a workforce spread across four states.
• Field education: Teach documentation in person, at stations, and during ride-alongs.
• Train-the-trainer: Train QI Coordinators, Field Supervisors, and clinical educators to deliver documentation instruction, so the program reaches crews this position cannot visit directly.
• Orientation: Teach the documentation portion of new employee orientation in Lafayette.
• Analysis and prioritization: Review audit findings, medic returns, and denial data to identify where patient care reports are incomplete, inconsistent, or unclear, and prioritize education toward the deficiencies that appear most often and matter most to patient care.
• Clinical education: Teach medics to write a record that accurately reflects the patient's condition and the care given: how the narrative, the assessment findings, and the clinical picture must agree with one another and support the decisions made in the field.
• EPCR program: Serve as a subject matter expert on the electronic patient care record and take part in the ePCR steering group. Help review, configure, and test changes to the ePCR, and train field personnel on them.
• Prevention: Recommend changes to EPCR templates, forms, and workflows that keep documentation errors from happening in the first place.
• Cross-department work: Work with Revenue Cycle and Operations on the documentation issues that affect medical necessity, insurance capture at the point of contact, and timely filing.
• Subject matter expertise: Advise field personnel, management, and standing committees, including the Billing and Documentation Resolution Committee, on clinical documentation.
• Reporting: Report documentation quality measures and program results to department leadership and the Executive Committee.

QUALIFICATIONS:

• Certification and experience: Nationally Registered and/or State Paramedic with a minimum of three (3) years of field experience. Candidates with a hospital Clinical Documentation Improvement background (CCDS, CDIP, CPC, RHIA, or equivalent) and a working understanding of prehospital care will also be considered.
• Teaching experience: Experience teaching or coaching adults, as an instructor, preceptor, field training officer, clinical educator, or in a similar role.
• Documentation knowledge: Good working knowledge of clinical documentation standards and of what establishes medical necessity for an ambulance transport.
• Writing: Able to write feedback that is specific, clinical, and useful to the medic receiving it.
• Data: Comfortable reading audit and denial reports, spotting patterns, and using them to decide where to teach.
• Location and travel: Must reside in Louisiana, Texas, Mississippi, or Tennessee, and must be able to travel throughout all four states to teach in person.
• Technology: Highly computer literate and comfortable adapting to new software.