Clinical Documentation Improvement Specialist (CDS) - CHC

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. Experience: Minimum of 3–5 years of acute care clinical nursing experience (ICU, Step-Down, Telemetry, or Med-Surg) or CDS/coding experience.

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.