Inpatient Clinical Documentation Specialist II

Beyond Blue Job Posting

Title:

Inpatient Clinical Documentation Specialist II

Requisition Number: R
- Department Name:
Supervisor, Inpatient Clinical Documentation

Work Location:

Remote-KY Grade Level: 11 Type of Position:
Regular Position Time Status:
Full time Equivalency Link (Use the "Apply for this Job" box below). Shift: Days (United States of America)

Responsible for ensuring accuracy, quality, and completeness of clinical documentation to support patient care, regulatory compliance, and appropriate reimbursement. Provides advanced expertise by collaborating with providers, coders, case managers, and the healthcare team to validate severity of illness, risk of mortality, and medical necessity. Conducts comprehensive chart reviews and clarifies provider documentation to improve clinical accuracy and data integrity. Coordinates reporting, trending, and analysis to support organizational quality initiatives and documentation integrity goals.

• Performs admission and continued stay reviews to validate principal diagnosis, comorbidities, and clinical indicators supporting severity of illness.
• Conducts follow-up reviews to confirm provider responses and integration of documentation into the medical record.
• Partners with coding specialists to resolve documentation and data discrepancies that impact coding accuracy and reimbursement.
• Develops and maintains data reports, spreadsheets, and dashboards to track trends and outcomes related to documentation integrity.
• Prepares summaries and presentations of review findings and documentation performance for leadership and hospital committees.
• Supports continuous improvement initiatives by identifying gaps in documentation and recommending process enhancements.
• Maintains current knowledge of coding, CDI practices, and regulatory changes to guide accurate documentation review.
• Performs other duties as assigned.

Associate’s degree

2+ years of related experience

An equivalent combination of education and experience may be considered. All experience must be paid and in the same related field. Part-time and PRN experience will be prorated based on hours worked per week. Volunteer work and internships for academic credit are not counted.

Registered Nurse

• A. Lifting, pushing, and/or pulling objects up to 50lbs:
  2.
• B. Lifting, pushing, and/or pulling objects over 50lbs:
  1.
• C. Standing or walking with objects up to 10lbs:
  3. Intermittent (10% - 50% of the time)
• D. Standing or walking with objects up to 25lbs:
  2. Occasional (< 10% of the time)
• E. Sitting at the computer workstation for extended periods:
  3. Intermittent (10% - 50% of the time)
• F. Risk of back injury from moving, lifting or positioning patients, equipment, or materials:
  2. Occasional (< 10% of the time)
• G. Repetitive motion:
  3. Intermittent (10% - 50% of the time)
• H. Working at heights above 4 feet:
  1. Never
• I. Working in confined spaces:
  1. Never
• J. Risk of injuries from use of equipment on the job:
  2. Occasional (< 10% of the time)
• K. Job-related travel:
  2. Occasional (< 10% of the time)
• L. Loud noises:
  1. Never
• M. Temperature extremes:
  1. Never
• N. Hazardous chemicals and fumes including waste:
  2. Occasional (< 10% of the time)
• O. Radiation:
  1. Never
• P. Burns:
  1. Never
• Q. Cuts/Punctures:
  2. Occasional (< 10% of the time)
• R. Bloodborne/airborne pathogens:
  2. Occasional (< 10% of the time)
• S. Recombinant DNA or viral vectors:
  1. Never
• T. Combative/violent people:
  1. Never
• U. Animal handling (including carcasses):1. Never
• V. Please specify other(s) and amount of exposure (i.e. Occasional, Intermittent or Regular): N/A

This position requires intermittent sitting at a computer workstation for extended periods of time; performing tasks with repetitive motions (such as typing); intermittent standing or walking with objects weighing up to 10 pounds; occasional standing or walking with objects weighing up to 25 pounds; and occasional lifting, pushing, or pulling objects weighing up to 50 pounds.

We value the well-being of each of our employees and are dedicated to creating a healthy…