Clinical Documentation Improvement Specialist (CDIS)

Hybrid Position- 2-3 days a week on site required

Schedule: Full Time

The Clinical Documentation Specialist (CDS) focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The CDS performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient’s severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The CDS utilizes advanced knowledge of disease processes, medications, and has critical thinking to analyze current documentation to identify gaps in clinical documentation. The CDS facilitates appropriate modifications to documentation through extensive interactions and collaborations with providers, coding, quality, and case management teams. This team member serves as an effective change agent as a resource and educator for providers and interdisciplinary care teams.

• Two years of experience as a Clinical Documentation Improvement Specialist
• Five years of adult acute care experience in med/surg, critical care, emergency, or PACU

• RN with CCS, BSN or MD required
• Current state Registered Nurse license
• Clinical Documentation Specialist credential (CDIP or CCDS), preferred; Upon hire must become AHIMA or ACDIS certified in CDI within 6 months of becoming eligible for the exam.
• Consideration will be provided for clinicians (i.e. graduates of medical schools outside the U.S. but not yet licensed to practice in the U.S.).

• Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems
• Demonstrated skills in analytical thinking, problem solving
• Effective verbal and written communication including ability to present ideas and concepts effectively to providers, leadership and other members of our healthcare team
• Demonstrated ability to work well with others in a creative and challenging work environment
• Self-motivated and able to work independently without close supervision
• Is proficient in the use of computers to perform daily work including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting tool.

• Periodically analyzes coding data to identify documentation variations and determine the cause and appropriateness of such variation; presents such findings to the management.
• Develop physician education strategies to promote complete and accurate clinical documentation and correct negative trends.
• Demonstrates an understanding of current Quality Measure Initiatives including Value Based Purchasing, Pay for Performance, and Readmission criteria.
• Monitors daily DRG assignment, DRG reports and tracking areas for performance improvement to appropriately reflect optimal severity at admission and through the stay.
• Facilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients at the Hospital for DRG based payers through concurrent interactions with physicians and other members of the health care team.
• Collaborates with the HIM coding staff to assist their understanding/clarification of documentation leading to appropriately assigning the DRG representing the patient severity of illness/resources consumption.

• Paid Major Holidays
• Generous Paid Time Off / Vacation
• Sick Time
• Health Insurance
• Dental Insurance
• Flexible Spending Accounts (FSA)
• Health Savings Account (HSA)
• Health Fitness & Education Class Discounts
• Employee Wellness Benefits
• Hospital Discount for Employees and Family
• VHC Retirement Program
• Tuition Reimbursement
• Career Coaching
• Family Leave
• 401(k) + Match
• and much more!