Clinical Documentation Specialist - FT - Days

Nursing (RN and LVN) Edinburg, Texas


Position at DHR Health



The role of Clinical Documentation Specialist of Clinical Documentation Improvement Department (CDI) works closely with the Director of CDI in addition to the other clinical documentation specialists, medical and coding staff in support of excellence in patient information documented in the medical record.


Primary purpose of this role is to provide oversite of the medical record that ensures care, and treatments are documented in support of patient care and accurate DRG assignment. The goal being to accurately define coding and documentation specificity by educating physicians, clinicians, and other interested parties regarding the necessity of providing complete and clear documentation of the care provided.


The role of Clinical Documentation Specialist of CDI will ensure the specialists review thorough and proper documentation during the patient’s stay. The Clinical Documentation Specialist of CDI will be accountable for the concurrent review of medical records to track documentation supporting the severity of the illness and resources utilized.


This position will use existing clinical knowledge from previous training to impart the values of clinical documentation to providers. This role will require utilize the candidate’s previous clinical experience in a hospital setting to leverage knowledge of clinical medicine in regards to the proper documentation needed on a daily basis. The role will require both onsite and off-site completion of daily job requirements in relation to clarifying clinical documentation and the accuracy of the medical record.



  • Medical graduate (M.D)/ Doctor of Osteopathy (D.O), Registered Nurse (R.N) or similar.
  • Proficiency in written and spoken English
  • CCS and/or CCA Exam certification within 2 years of employment or CCDS Exam certification within 2 years of employment.
  • Able to meet the requirements for CCS and/or CCA Exam requirements either based on experience or education as detailed on the AHIMA or the CCDS Exam requirements as detailed on the ACDIS website.



  • Minimum 1+ year clinical experience in acute care setting
  • Knowledge of EMR and related medical record documents, coding and documentation.
  • Knowledge of disease process and pathology amongst various patient populations
  • Knowledge of treatment modalities for disease process and pathologies
  • Strong understanding of anatomy, pathology, pharmacology and physiology of disease process.
  • Excellent written, verbal communication skills and critical thinking skills.
  • Able to work with teams and independently.




  • Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices.
  • Reviews clinical documentation for improvement opportunities.
  • Intervene with Clinical and Medical Staff to ensure documentation supporting applicable diagnosis
  • Provide education to physicians and other clinicians on compliant documentation practices to support severity and continuity of patient care. Acts as an effective change agent and educator for physicians and allied health staff.
  • Serves as a clinical resource to the coding staff when coders require clinical interpretation to determine appropriate code assignment.
  • The Clinical Documentation Specialist facilitates clarification to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients. The Clinical Documentation Specialist will:  
  • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans.
  • Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
  • Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
  • Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
  • Gather and analyze information pertinent to documentation findings and outcomes.
  • Supports development of templates, databases and other tools to support accurate documentation. Provides reports to manager as requested. Maintains a strong knowledge of DRG methodology, severity of illness/risk of mortality statistics, and coding guidelines.
  • Possesses strong understanding of the requirements for clinical coding and billing according to the rules for Medicare, Medicaid, and commercial health plans.




(Clinical Documentation Specialist)       →        2. (Director of CDI)      →        3. (CFO)