Clinical Documentation Specialist - Hybrid

Community Health Systems • Anchorage, AK

10d • 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 medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.

This position is hybrid in Matsu, Alaska, at Laredo Medical Center. The CDS analyzes inpatient clinical records, identifies documentation opportunities, follows approved CDI workflows, and uses CDI and medical records software. The role also tracks CDI activities and impact metrics, collaborates with coding professionals, educates providers, monitors regulatory changes, and submits accurate reports. The position maintains regular and reliable attendance, complies with policies and standards, and performs other duties as assigned.

Requirements

• Associate degree in Nursing or a comparable clinical field, such as an International MD, required.
• Three to five years of acute care hospital nursing experience, such as on a medical/surgical unit or in intensive care, required.
• Registered Nurse state licensure and/or compact state licensure, or a comparable clinical license such as an International MD, required.
• Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
• Excellent analytical and problem-solving skills to identify documentation improvement opportunities.
• Proficiency in CDI and medical record software systems.
• 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.

Nice To Haves

• Bachelor's degree in Nursing, Health Information Management, or a related field preferred.
• Three to five 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.
• CCS (Certified Coding Specialist), ICD-10 certification, or trainer designation preferred.
• CCDS (Certified Clinical Documentation Specialist) preferred.
• RHIT (Registered Health Information Technician) preferred.
• RHIA (Registered Health Information Administrator) preferred.
• CDIP (Clinical Documentation Improvement Professional) preferred.
• Certified Coder-AHIMA or AAPC preferred.

Responsibilities

• Analyze inpatient clinical records to identify opportunities to improve documentation accuracy 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, ensure 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 ensure accuracy through continuous review.
• Track CDI activities in CDI software, report impact metrics accurately, and maintain clear records of interactions and documentation efforts.
• Educate providers about 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 relevant information with staff.
• Create and submit accurate reports in a timely manner and maintain current knowledge of best practices and industry standards to support CDI goals.
• Maintain regular and reliable attendance and comply with all policies and standards.
• Perform other duties as assigned.

What This Job Offers

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