Review inpatient records to improve clinical documentation accuracy, ensure coding reflects patient severity, manage physician queries, track CDI metrics, provide provider education, collaborate with coding teams, and maintain regulatory compliance using CDI and medical records software.
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
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.
- 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
- 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.
- 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
Similar Jobs
Healthtech
Perform clinical documentation improvement by reviewing inpatient records, querying providers, collaborating with coding teams, tracking CDI metrics, and delivering education to ensure accurate coding, regulatory compliance, and quality reporting.
Top Skills:
3M 360 EncompassIodine Interact
Healthtech • Other
Evaluate and improve inpatient clinical documentation quality and completeness to ensure accurate severity capture for payers. Collaborate with coding staff and medical staff, perform targeted reviews, track program metrics, educate clinicians, and support documentation needs for new service lines.
Healthtech • Other
Review and improve inpatient clinical documentation to ensure accuracy for Medicare/Medicaid and other payers. Collaborate with coding staff and medical staff, perform targeted reviews (e.g., DRG outliers), educate providers, monitor program metrics, and support documentation needs for new service lines to accurately reflect patient severity and outcomes.
What you need to know about the Los Angeles Tech Scene
Los Angeles is a global leader in entertainment, so it’s no surprise that many of the biggest players in streaming, digital media and game development call the city home. But the city boasts plenty of non-entertainment innovation as well, with tech companies spanning verticals like AI, fintech, e-commerce and biotech. With major universities like Caltech, UCLA, USC and the nearby UC Irvine, the city has a steady supply of top-flight tech and engineering talent — not counting the graduates flocking to Los Angeles from across the world to enjoy its beaches, culture and year-round temperate climate.
Key Facts About Los Angeles Tech
- Number of Tech Workers: 375,800; 5.5% of overall workforce (2024 CompTIA survey)
- Major Tech Employers: Snap, Netflix, SpaceX, Disney, Google
- Key Industries: Artificial intelligence, adtech, media, software, game development
- Funding Landscape: $11.6 billion in venture capital funding in 2024 (Pitchbook)
- Notable Investors: Strong Ventures, Fifth Wall, Upfront Ventures, Mucker Capital, Kittyhawk Ventures
- Research Centers and Universities: California Institute of Technology, UCLA, University of Southern California, UC Irvine, Pepperdine, California Institute for Immunology and Immunotherapy, Center for Quantum Science and Engineering
