Clinical Documentation Improvement Specialist (Cds) - Chc

Wylie, TX
Full-time

Job description

Facility Type
Long Term Acute Care
Overview
The Clinical Documentation Specialist (CDS) - LTACH evaluates patient medical records to
ensure clinical documentation accurately reflects the complexity of care, severity of illness
(SOI), risk of mortality (ROM), and resource utilization specific to long-term acute care patients. Operating in an environment focused on complex, extended-stay medical cases—such as prolonged mechanical ventilation, severe wound care, and multi-organ failure—the CDS collaborates directly with physicians, interdisciplinary care teams, and coders to bridge clinical findings and compliant documentation.
Responsibilities
Primary Responsibilities
Concurrent & Retrospective Review
• Conduct daily concurrent reviews of inpatient medical records for assigned LTACH beds.
• Audit admission notes, progress notes, procedure reports, diagnostic findings, and

discharge summaries for accuracy, completeness, and specificity.
• Monitor for clinical indicators of secondary diagnoses, comorbidities, or complications

(e.g., acute respiratory failure, severe sepsis, Stage III/IV pressure injuries, protein-calorie
malnutrition).
Provider Collaboration & Query Process
• Initiate compliant written or verbal queries to attending physicians, pulmonologists, and

specialists when documentation is vague, ambiguous, or lacks clinical validation.
• Ensure all queries follow AHIMA, ACDIS, and CMS compliant query guidelines

(non-leading).
• Conduct follow-up record reviews after queries are placed to verify appropriate provider

responses in the Electronic Health Record (EHR).
LTACH Regulatory & Quality Compliance
• Ensure documentation meets LTACH Prospective Payment System (MS-LTC-DRG)

criteria, including qualifying length-of-stay thresholds and primary LTACH diagnostic
criteria.
• Support the accurate capture of Quality Reporting Program (QRP) data, post-acute care

quality measures, and patient risk adjustment data.
• Participate in pre-bill chart audits to reduce billing delays, avoid improper payment

denials, and optimize compliant reimbursement.
Staff Education & Support
• Provide continuous coaching and formal education to physicians, mid-level providers, and

clinical staff on documentation requirements, Medicare guidelines, and coding specificity.
• Serve as a liaison between the clinical nursing/medical staff and the HIM coding team.

Qualifications
Key Requirements & Qualifications
• Education: Graduate of an accredited School of Nursing (BSN preferred) or Health

Information Management program.
• Licensure / Certification:
• Active Registered Nurse (RN) license, OR RHIA / RHIT certification.
• Preferred: Certified Clinical Documentation Specialist (CCDS) or Certified Document

Integrity Specialist (CDIP) credential.
• Experience:
• Minimum of 3–5 years of acute care clinical nursing experience (ICU, Step-Down,

Telemetry, or Med-Surg) or CDS/coding experience.
• Prior LTACH, rehabilitation, or post-acute care documentation experience preferred.
• Skills & Knowledge:
• Deep clinical understanding of complex disease processes, diagnostic criteria, and

pharmacology.
• Strong knowledge of ICD-10-CM coding conventions, MS-DRG / MS-LTC-DRG

assignment, and CMS guidelines.
• Proficiency with Electronic Health Record (EHR) systems (e.g., Epic, Cerner, Meditech)

and CDI tracking software.
• Excellent verbal and written communication skills to effectively collaborate with medical

staff.
Working Conditions
• Environment: On-site hospital environment with hybrid remote options depending on

facility structure.
• Physical Demands: Prolonged periods of sitting, viewing computer screens, and

performing detailed chart reviews.
Primary Responsibilities
Concurrent & Retrospective Review
• Conduct daily concurrent reviews of inpatient medical records for assigned LTACH beds.
• Audit admission notes, progress notes, procedure reports, diagnostic findings, and