Clinical Documentation Specialist (2026-0737)

Location: Renton, WA – VMC Main Campus, Health Information Management department

Full-time, days (Monday - Friday, typically 7:00 AM - 3:30 PM; flexibility may be required)

About the role

The Clinical Documentation Specialist ensures the medical record accurately reflects the patient’s clinical condition, severity of illness, risk of mortality, quality outcomes, and services provided. This position serves as a liaison between providers, coding professionals, case management, quality, and revenue cycle teams to improve documentation accuracy, support complete coding and billing compliance, and drive organizational initiatives.

Responsibilities

• Conduct comprehensive reviews of electronic medical records (EMRs) to ensure documentation is complete, accurate, and clinically supported, reflecting severity of illness (SOI), risk of mortality (ROM), quality indicators, and documentation integrity using approved Clinical Documentation Integrity (CDI) methodologies.
• Perform accurate, timely concurrent and retrospective medical record reviews to ensure documentation supports the patient’s clinical condition, quality outcomes, and compliant coding practices.
• Assign a working APR-DRG and severity level using applicable coding rules and guidelines; conduct follow-up reviews according to established length-of-stay (LOS) standards.
• Collaboratively resolve CDI-coder DRG discrepancies in accordance with established reconciliation processes.
• Analyze clinical information to identify documentation gaps, inconsistencies, and opportunities for improvement.
• Identify opportunities to improve physician documentation related to principal diagnoses, secondary diagnoses, comorbidities, complications, present-on-admission (POA) indicators, quality measures, and patient safety indicators (PSIs).
• Develop and communicate clinically supported, industry-standard documentation clarification queries that promote accurate, complete, and compliant clinical documentation for:
  • Principal diagnoses
  • Comorbidities
  • Present on Admission (POA) indicators
  • Quality measures
  • Patient safety indicators
  • Regulatory requirements
• Utilize established workflows and communication processes to collaborate with physicians and interdisciplinary care teams regarding documentation opportunities.
• Identify barriers to achieving documentation improvement goals and implement appropriate interventions.
• Follow up on all cases requiring clinical documentation clarification and ensure resolution in accordance with departmental processes.
• Work with the CDI Manager to resolve documentation discrepancies, clinical validation concerns, and escalation issues to ensure timely provider responses.
• Maintain proficiency in applicable coding, reimbursement, and regulatory guidelines in accordance with organizational and industry standards.
• Provide education and guidance to physicians, advanced practice providers, coding staff, and other healthcare professionals regarding documentation requirements and improvement opportunities.
• Participate in education initiatives for physicians, providers, CDI staff, and coding staff regarding documentation regulations, coding guidelines, quality measures, audit findings, and documentation improvement opportunities.
• Meet established productivity, quality, and performance standards upon completion of training.
• Participate in the orientation, training, and onboarding of new CDI staff members.
• Engage in organizational initiatives, performance improvement activities, and interdisciplinary projects that support documentation quality and organizational goals.
• Demonstrate awareness of cost containment principles and identify opportunities for process improvement, quality enhancement, and operational efficiency.
• Maintain working knowledge of clinical documentation integrity practices, coding conventions and guidelines, reimbursement methodologies, and regulatory requirements.
• Maintain ongoing professional development through participation in relevant professional organizations.
• Adhere to all hospital policies, procedures, and standards of conduct.
• Maintain confidentiality of all protected health information in accordance with applicable regulations and organizational policies.
• Perform other duties as assigned to support the accurate, compliant, and efficient operation of the revenue cycle and organization.

Requirements

• Current unrestricted Registered Nurse (RN) license in the State of Washington.
• Minimum five years recent clinical experience as a Registered Nurse in an acute care inpatient hospital setting, or minimum of three years acute care inpatient hospital setting combined with at least one year of inpatient Clinical Documentation Specialist experience.
• Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Specialist - Outpatient (CCDS-O) strongly preferred.
• Experience with EPIC (Resolute) or similar EHR required.
• Proficient in Microsoft Office applications (Excel, Word, PowerPoint, Visio, Outlook).

Qualifications

• Understanding of MS-DRGs, APR-DRGs, Severity of Illness (SOI), Risk of Mortality (ROM), Hierarchical Condition Categories (HCCs), and value-based reimbursement methodologies.
• Proven ability to build collaborative partnerships with physicians and departments to drive organizational initiatives.
• Exceptional organizational and self-management skills; ability to prioritize, multitask, and manage multiple projects in a fast-paced, deadline-driven environment.
• Effective communicator with ability to facilitate discussions and present clearly to groups.
• Ability to remove technical and cultural barriers to achieve operational objectives.
• Comprehensive knowledge of disease processes, clinical terminology, anatomy, and physiology.
• Familiarity with compliant physician query practices and clinical validation principles.
• Comprehensive knowledge of industry standards, regulatory requirements, and best practices to ensure successful project delivery in alignment with departmental objectives.
• Excellent organizational and interpersonal skills; ability to work collaboratively across departments in a matrix environment.
• Strong verbal, written, and presentation communication skills.
• Self-motivated, results-oriented, and able to work independently with minimal direction.
• Demonstrated critical thinking, clinical judgment, problem-solving, and deductive reasoning skills.

Working Conditions

• Ability to work independently, take initiative in problem-solving, and interact professionally with a wide variety of people, including staff, providers, and the public.
• Attention to detail and excellent organizational skills are essential.
• Ability to function effectively in an environment with frequent interruptions and multiple tasks.
• Proficiency in interacting with patient access and billing systems, third-party software, spreadsheets, and meeting minutes.
• Requires manual and finger dexterity and vision corrected to normal range.
• Prolonged periods of sitting and exposure to computer monitor and keyboarding.

Pay

Salary range: $94,894 – $142,341 annually, dependent on experience.