Sr. Clinical Documentation Specialist

Ascension•Murfreesboro, TN

5d•Onsite

About The Position

This role serves as the resident Clinical Documentation Integrity (CDI) subject matter expert, guiding regional initiatives and mentoring colleagues across clinical and coding domains. The specialist will analyze high-complexity medical records, evaluating clinical indicators, comorbidities, severity of illness, and risk of mortality to ensure accurate DRG assignment and diagnosis capture. A key aspect of the role involves building direct partnerships with physicians and APPs, issuing compliant, non-leading queries to clarify documentation and reflect the true level of care provided. The specialist will also champion quality improvement projects and ensure all clinical documentation practices strictly align with regulatory standards and coding guidelines.

Requirements

Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree with 1 year of experience OR 5 years of applicable cumulative job specific experience required.

Nice To Haves

2 years of leadership or management experience preferred.

Responsibilities

Serve as the resident Clinical Documentation Integrity (CDI) subject matter expert, guiding regional initiatives and mentoring colleagues across clinical and coding domains.
Review high-complexity cases—evaluating clinical indicators, comorbidities, severity of illness, and risk of mortality—to ensure accurate DRG assignment and diagnosis capture.
Build direct partnerships with physicians and APPs, issuing compliant, non-leading queries to clarify documentation and reflect the true level of care provided.
Champion quality improvement projects and ensure all clinical documentation practices strictly align with regulatory standards and coding guidelines.