Job Description

A forward-thinking hospital group is redefining healthcare delivery to rural communities across the Southwest. With a growing network of eight micro-hospitals spanning Arizona, New Mexico, Oklahoma, and Texas, they’re on an ambitious path—opening 2-3 hospitals annually through acquisitions and strategic initiatives. Their commitment to growth, innovation, and exceptional care is unwavering.

As they expand, they’re seeking a Clinical Documentation Improvement Specialist (CDIS) to elevate the accuracy, integrity, and impact of clinical documentation in a fast-paced, evolving healthcare environment.

This full-time, on-site role is based at their Scottsdale, AZ offices.

Position Summary:

The CDIS will be responsible for improving the overall quality and accuracy of clinical documentation, ensuring compliance with regulatory requirements, optimizing reimbursement, and enhancing patient care outcomes. The ideal candidate will collaborate closely with physicians, nurses, coders, and other healthcare professionals to promote accurate and thorough documentation of patient records.

Responsibilities:

• Review inpatient and outpatient medical records to ensure the accuracy, completeness, and compliance of clinical documentation with regulatory and organizational standards.
• Identify opportunities to improve the specificity and clarity of clinical documentation to reflect the patient’s clinical status and treatment provided.
• Collaborate with healthcare providers to clarify documentation, using effective communication and query techniques to obtain additional information when necessary.
• Educate and train physicians, advanced practice providers, and other clinical staff on best practices for documentation improvement and regulatory changes.
• Analyze and monitor documentation and coding trends to identify areas of improvement and recommend strategies to enhance compliance and efficiency.
• Work closely with coding professionals to ensure proper coding and reimbursement practices align with documentation.
• Participate in regular audits, reviews, and quality improvement initiatives to ensure continuous improvement in documentation standards.
• Maintain up-to-date knowledge of healthcare regulations, coding guidelines (ICD-10-CM/PCS), and reimbursement methodologies (DRG, MS-DRG, APR-DRG).
• Ensure adherence to HIPAA and other patient privacy and confidentiality regulations.

Qualifications:

• Bachelor’s degree in Nursing (BSN), Health Information Management (HIM), or a related healthcare field. Advanced clinical degrees preferred.
• 3-5 years of clinical or healthcare experience in a hospital setting, with direct experience in clinical documentation improvement.
• Certified Clinical Documentation Improvement Specialist (CCDS or CDIP) or equivalent required.
• Strong understanding of clinical documentation requirements, medical terminology, anatomy, and physiology.
• Expertise in ICD-10-CM/PCS coding systems and DRG structures.
• Proficiency in querying guidelines and regulatory compliance (CMS, Joint Commission).
• Excellent analytical, organizational, and communication skills.
• Ability to work collaboratively with multidisciplinary teams.

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