Lead Clinical Documentation Specialist, RN - Health Informat

Hawai'i Pacific Health is a not-for-profit health care network with over 70 locations statewide, including medical centers, clinics, physicians and other caregivers serving Hawai'i and the Pacific Region with high quality, compassionate care. Its four medical centers – Kapi'olani, Pali Momi, Straub and Wilcox – specialize in innovative programs in women’s health, pediatric care, cardiovascular services, cancer care, bone and joint services and more.

Hawai'i Pacific Health is recognized nationally for its excellence in patient care and the use of electronic health records to improve quality and patient safety.

Health Information Services (HIS) processes patient medical records and releases health information to patients, physicians, and other outside facilities for treatment, payment, or review. HIS is the custodian and gatekeeper for privacy of the organization’s medical records and also generates the coding procedures for data collection, research, and reimbursement. With the widespread computerization of health records and other information sources, including hospital administration functions and health human resources information, health informatics and health information technology are being increasingly used in the health care sector.

Hawai‘i Pacific Health is seeking a Lead Clinical Documentation Specialist (CDS) – RN to support and elevate the quality, accuracy, and completeness of clinical documentation across our hospitals.

In this role, you will conduct concurrent reviews, identify documentation improvement opportunities, and collaborate closely with physicians, clinicians and coding teams to ensure medical records accurately reflect severity of illness and support compliant ICD‑10‑CM/PCS coding. You will help drive CDI program excellence by training new and existing CDS nurses, leading documentation improvement initiatives, supporting DRG reconciliation efforts, and providing targeted physician education.

This role also analyzes data trends, refines processes, and partners with internal and external stakeholders to advance documentation integrity system‑wide. You will work independently, thrive in a diverse professional setting, and share our commitment to a healthier Hawai‘i.

Harbor Court (On-site position; not a hybrid nor work‑from‑home position)

Day – 8 Hours

Full Time Regular

1.000000

Non‑Bargaining

Yes

32314

–  USD per hour

Health Information Management

Bachelor’s Degree and/or equivalent combination of training, and/or experience in Nursing or related field. Must meet education requirements for Hawai‘i state licensing. Current Hawai‘i RN license. Five years of acute care nursing experience demonstrating progressive experience in reviewing medical records and/or compliance of medical record documentation. Two years of hospital‑based inpatient CDI and coding experience. Professional knowledge of DRGs and other reimbursement methodologies as well as official coding guidelines for inpatient ICD‑CM/PCS coding.

Knowledge of medical terminologies, anatomy & physiology, disease processes, pharmacology drug names. Proficient in Microsoft Office, including Outlook, Word, Excel, PowerPoint or Access. Must obtain the Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP) certification within one year of hire.

ICD‑10 Trainer certification or Certified Coding Specialist (CCS). Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP). Previous leadership experience. Previous training/preceptor experience.

EOE/AA/Disabled/Vets

Hawai‘i Pacific Health offers a comprehensive and competitive total rewards package that includes pay and benefits. Rate of pay for selected candidates will be determined by various factors including knowledge, skills, abilities, relevant experience and training, as well as internal peer equity.