Clinical Documentation Specialist - Hybrid (Lutheran)

Community Health Systems • Fort Wayne, IN

5d • 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 patients’ clinical status and the care provided. The CDS collaborates with providers through education and the physician query process so medical records accurately represent patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.

The position is hybrid at Lutheran Hospital in Fort Wayne, Indiana. The CDS uses CDI and medical records software, including 3M 360 Encompass and Iodine Interact, and follows corporate-recommended CDI workflows, approved query processes, and applicable policies and standards.

Requirements

• Associate degree in Nursing or a comparable clinical field (e.g., 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 (e.g., International MD).
• 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, such as 3M 360 Encompass and 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.

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, or CCDS (Certified Clinical Documentation Specialist).
• RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator).
• CDIP (Clinical Documentation Improvement Professional), Certified Coder-AHIMA, or Certified Coder-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; 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 and train 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; maintain compliance with updated standards and share information with staff as needed.
• Create and submit accurate reports in a timely manner and maintain knowledge of best practices and industry standards to support CDI goals.
• Perform other duties as assigned.
• Maintain regular and reliable attendance and comply with all policies and standards.

What This Job Offers

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