Clinical Documentation Specialist - Hybrid

Community Health Systems • Las Cruces, NM

9d • Hybrid

About The Position

The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. The role ensures 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 so that medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.

The position is hybrid at Mountain View Medical Center. The CDS analyzes inpatient clinical records, conducts follow-up reviews, tracks CDI activities and impact metrics, and prepares accurate reports. The specialist works with providers and coding professionals, leads physician education initiatives, and monitors regulatory changes affecting coding, documentation, and quality metrics. The role also maintains regular and reliable attendance, complies with applicable policies and standards, and performs other duties as assigned.

Requirements

• Associate degree in Nursing or a comparable clinical field, such as an International MD.
• 3–5 years of acute care hospital nursing experience, such as on a medical/surgical unit or in intensive care.
• RN state licensure and/or compact state licensure, or a comparable clinical license such as an International MD.
• Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
• Strong analytical and problem-solving skills to identify documentation improvement opportunities.
• Proficiency in CDI and medical record software systems.
• Effective communication and interpersonal skills for collaborating with physicians and interdisciplinary teams.
• Ability to develop and deliver educational programs for 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.

Nice To Haves

• Bachelor's degree in Nursing, Health Information Management, or a related field.
• 3–5 years of experience in clinical documentation improvement, health information management, or inpatient coding.
• Experience in physician education or query processes.
• Familiarity with regulatory standards and quality metrics related to clinical documentation.
• CCS (Certified Coding Specialist), ICD-10 certification, or trainer designation.
• Certified Clinical Documentation Specialist (CCDS).
• RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator).
• CDIP (Clinical Documentation Improvement Professional).
• Certified Coder-AHIMA or AAPC.

Responsibilities

• Analyze inpatient clinical records to identify documentation improvement opportunities and ensure assigned codes reflect patient severity and acuity.
• Follow corporate-recommended CDI workflows and use CDI and medical records software to support documentation practices.
• Use approved physician query processes to clarify documentation, ensuring 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 verify accuracy through continuous review.
• Track CDI activities in CDI software, accurately report impact metrics, and maintain clear records of interactions and documentation efforts.
• Educate and train providers on 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.
• Maintain regular and reliable attendance, comply with policies and standards, and perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree