Clinical Document Nurse Specialist

United Regional • Wichita Falls, TX

8d

About The Position

Clinical Documentation Specialist Summary of Essential Functions The CDI Specialist is responsible for improving the accuracy, completeness, and clarity of clinical documentation to ensure the medical record accurately reflects the patient’s severity of illness, risk of mortality, and level of care. This role requires strong clinical judgment, advanced critical thinking, and the ability to interpret complex clinical data such as labs, diagnostics, and treatment plans. The CDI Specialist is a key partner in supporting compliant documentation, accurate coding, and organizational quality outcomes. Educational Requirements High school diploma or equivalent required. Associates Degree in Nursing required. BSN preferred. License and Certifications Registered with the Board of Nursing for the State of Texas. Clinical Documentation Specialist Certification preferred Qualifications/Knowledge/Skills/Abilities Minimum of four years of acute care hospital experience, critical care experience preferred. Knowledge of contents and use of end coder is essential, or proficiency achieved within 6 months of hire. Strong understanding of pathophysiology and clinical disease progression. Ability to interpret and apply diagnostic data (labs, imaging, medication and clinical indicators) Strong analytical/problem-solving skills, ability to integrate knowledge with job situations. Excellent oral/written communication skills. Ability to strongly communicate and interact with all levels of professionals, including but not limited to physicians and nursing personnel, managers, various support staff departments, physician offices, in a non-confrontational manner. Must be able to communicate complex regulatory and clinical information in understandable terms. Excellent interpersonal skills. Must be able to communicate effectively with various System audiences. Understands and applies the principles of customer service, service recovery. Must be thorough in reporting information to supervisor. Strong knowledge of billing/coding, healthcare reimbursement. Personal computer skills with emphasis on Microsoft Word, Excel and Access database program. Demonstrates an ability to be flexible, organized and function under stressful situations. Physical Requirements Ability to move throughout clinical units and sit for extended periods of time. Occasionally lifting up to 25 lbs.

Requirements

• High school diploma or equivalent required.
• Associates Degree in Nursing required.
• Registered with the Board of Nursing for the State of Texas.
• Minimum of four years of acute care hospital experience, critical care experience preferred.
• Knowledge of contents and use of end coder is essential, or proficiency achieved within 6 months of hire.
• Strong understanding of pathophysiology and clinical disease progression.
• Ability to interpret and apply diagnostic data (labs, imaging, medication and clinical indicators)
• Strong analytical/problem-solving skills, ability to integrate knowledge with job situations.
• Excellent oral/written communication skills.
• Ability to strongly communicate and interact with all levels of professionals, including but not limited to physicians and nursing personnel, managers, various support staff departments, physician offices, in a non-confrontational manner.
• Must be able to communicate complex regulatory and clinical information in understandable terms.
• Excellent interpersonal skills.
• Must be able to communicate effectively with various System audiences.
• Understands and applies the principles of customer service, service recovery.
• Must be thorough in reporting information to supervisor.
• Strong knowledge of billing/coding, healthcare reimbursement.
• Personal computer skills with emphasis on Microsoft Word, Excel and Access database program.
• Demonstrates an ability to be flexible, organized and function under stressful situations.

Nice To Haves

• BSN preferred.
• Clinical Documentation Specialist Certification preferred
• critical care experience preferred.

Responsibilities

• Works closely with and maintains positive open communication with Corporate Compliance Officer, Medical Management leadership, Physicians, Medical Record Coders, Case Managers, Utilization Review and Nursing Staff to accomplish the objectives of the Compliant Documentation Management Program.
• Facilitates accurate, complete clinical documentation by performing admission reviews that ensure the patient’s acuity and level of services are appropriately reflected in the medical record.
• Assists in the medical screening process assigning a working DRG for patients reviewed, uses clinical judgment and pathophysiologic knowledge to identify documentation gaps to ensure appropriate DRG, LOS, SOI/ROM and risk adjustment are assigned.
• Performs follow-up review of all charts within 48 hours to ensure issues discussed and clarified with the physician have been recorded in the patient’s chart, and updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with the physician to finalize diagnoses.
• Ensures concurrent documentation across disciplines to accurately capture Quality Indicators for select diagnoses and meet CMS and JCAHO quality reporting standards.
• Educate providers and internal stakeholders on documentation best practices, clinical indicators, and CMS/Coding requirements
• Maintain a strong understanding of CMS guidelines, coding rules, and CDI best practices
• Participate in performance improvement, audits, and program development activities
• Adapt to evolving regulations, workflows, and organizational priorities
• Performs all other tasks/responsibilities as necessary.

What This Job Offers

• Career Level: Mid Level
• Education Level: Associate degree