Clinical Documentation Improvement Specialist (CDS) - CHC

Facility Type

Long Term Acute Care
Overview

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.

Responsibilities

Primary Responsibilities
Concurrent & Retrospective Review
● 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.

Qualifications

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.