HIM Clinical Document Specialist, UMMC

About the role

The Clinical Documentation Specialist (CDS) works under the direction of the Site Manager of the Clinical Documentation Integrity (CDI) program to ensure accurate and complete documentation in inpatient medical records. This role supports precise ICD-10-CM and ICD-10-PCS coding and reporting of high-quality healthcare data, guided by the Association of Clinical Documentation Integrity Specialists (ACDIS) “Code of Ethics,” the American Health Information Management Association’s (AHIMA) “Ethical Standards for Clinical Documentation Integrity Professionals,” and the Official Guidelines for Coding and Reporting.

Responsibilities

• Performs concurrent initial chart reviews within 24-48 hours after admission, with follow-up reviews every 1-3 days, and retrospective chart reviews as applicable. Ensures accurate assignment/capture of APR-DRG, severity of illness (SOI), and risk of mortality (ROM) to reflect quality indicators, resource consumption, and outcome measures. Analyzes clinical status, treatment plans, and medical history to identify documentation gaps.
• Communicates with providers verbally or in writing to validate observations. Develops compliant provider queries per organizational and AHIMA standards for conflicting, incomplete, or ambiguous documentation. Uses clinical expertise, critical thinking, and data analysis to clarify complex cases, add detail to diagnoses, verify Present on Admission (POA) status, and establish clinical significance.
• Identifies education opportunities based on query topics or documentation needs. Collaborates with providers, leadership, and teams to develop tools and materials supporting accurate documentation. Participates in formal and informal education sessions (e.g., presentations, in-services, newsletters) and attends clinical program and CDI meetings. Implements strategies for sustained documentation accuracy.
• Acts as a clinical liaison between HIM/coding staff and providers. Partners with coding professionals to reconcile diagnostic and procedural data, validating CDS Final APR-DRG/SOI/ROM against Final Coded APR-DRG/SOI/ROM.
• Pursues continuing education to stay current on CDI matters and maintain credentials.

Requirements

• Associate’s Degree.
• Licensure as a Registered Nurse (RN), Physician (MD), Physician Assistant (PA), or Certified Registered Nurse Practitioner (CRNP).
• Minimum of 2 years of experience reviewing inpatient medical records as a Clinical Documentation Integrity Specialist, Coder/DRG Analyst with clinical background, Care Manager, Utilization Review Specialist, or Quality Review Specialist; or minimum of 3 years of chart abstraction/chart review experience.
• Must obtain certification as a Certified Clinical Documentation Specialist (CCDS) via ACDIS or Certified Documentation Integrity Practitioner (CDIP) via AHIMA within 2 years of hire or eligibility. (Employees hired prior to 1/1/2023 without licensure are grandfathered if they meet experience and certification requirements.)

Preferred Qualifications

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) at time of hire.
• Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).