Clinical Documentation Improvement Specialist (CDS) - CHC

Vibra Travels • Abilene, TX

6d • Hybrid

About The Position

The Clinical Documentation Improvement Specialist (CDS) evaluates patient medical records in a long-term acute care hospital (LTACH) to ensure documentation accurately reflects complexity of care, severity of illness, risk of mortality, and resource utilization. The role focuses on complex, extended-stay cases, including prolonged mechanical ventilation, severe wound care, and multi-organ failure, and collaborates with physicians, interdisciplinary care teams, and coders to connect clinical findings with compliant documentation.

The CDS conducts concurrent and retrospective record reviews, identifies documentation gaps and clinical indicators for diagnoses, and initiates compliant queries with providers. The role also supports LTACH regulatory and quality requirements, pre-bill audits, accurate quality and risk-adjustment data, and staff education. The position is based in an on-site hospital environment, with hybrid remote options depending on facility structure.

Requirements

• Graduate of an accredited School of Nursing or Health Information Management program; BSN preferred.
• Active Registered Nurse (RN) license or RHIA/RHIT certification.
• Minimum of 3–5 years of acute care clinical nursing experience in ICU, Step-Down, Telemetry, or Med-Surg, or CDS/coding experience.
• Deep clinical understanding of complex disease processes, diagnostic criteria, and pharmacology.
• Strong knowledge of ICD-10-CM coding conventions, MS-DRG/MS-LTC-DRG assignment, and CMS guidelines.
• Proficiency with EHR systems and CDI tracking software.
• Excellent verbal and written communication skills for collaboration with medical staff.

Nice To Haves

• BSN.
• Certified Clinical Documentation Specialist (CCDS) or Certified Document Integrity Specialist (CDIP) credential.
• Prior LTACH, rehabilitation, or post-acute care documentation experience.
• Experience with EHR systems such as Epic, Cerner, or Meditech.

Responsibilities

• Conduct daily concurrent reviews of inpatient medical records for assigned LTACH beds.
• Audit admission notes, progress notes, procedure reports, diagnostic findings, and discharge summaries for accuracy, completeness, and specificity.
• Monitor records for clinical indicators of secondary diagnoses, comorbidities, or complications, such as acute respiratory failure, severe sepsis, Stage III/IV pressure injuries, and protein-calorie malnutrition.
• Initiate compliant written or verbal queries to attending physicians and specialists when documentation is vague, ambiguous, or lacks clinical validation.
• Ensure queries follow AHIMA, ACDIS, and CMS guidelines and are non-leading.
• Conduct follow-up record reviews after queries to verify provider responses in the EHR.
• Ensure documentation meets LTACH Prospective Payment System (MS-LTC-DRG) criteria, including qualifying length-of-stay thresholds and primary LTACH diagnostic criteria.
• Support accurate capture of Quality Reporting Program data, post-acute care quality measures, and patient risk-adjustment data.
• Participate in pre-bill chart audits to reduce billing delays, avoid improper payment denials, and optimize compliant reimbursement.
• Provide ongoing coaching and formal education to physicians, mid-level providers, and clinical staff on documentation requirements, Medicare guidelines, and coding specificity.
• Serve as a liaison between clinical nursing and medical staff and the HIM coding team.

What This Job Offers

• Job Type: Full-time