Clinical Documentation Improvement Specialist; CDS; CHC

Long Term Acute Care

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.

Primary Responsibilities

• 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.

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.