Professional Clinical Documentation Specialist

Everything we do is underscored by a why - and that why is one another.

Location

Altru Health System PO Box 6002 Grand Forks, ND 58201

Pay Range: $73,819.20 - $110,718.40

Summary

The Ambulatory Clinical Documentation Specialist (CDS) serves as an advisor and expert resource to providers, supporting accurate and complete clinical documentation that reflects patient complexity, risk profiles, and appropriate Evaluation and Management (E/M) service levels. This role supports professional fee billing accuracy, appropriate reimbursement, and compliance with applicable regulatory and industry standards.

The Ambulatory CDS identifies clinically relevant information and documentation opportunities through comprehensive chart review. The role focuses on the recapture and identification of chronic conditions represented by Hierarchical Condition Categories (HCCs), which contribute to a patient’s risk-adjusted profile and Risk Adjustment Factor (RAF) score. The CDS also evaluates documentation and medical decision making to identify opportunities to appropriately reflect the level of service provided.

The Ambulatory CDS performs pre-visit and post-claim reviews and provides clear, actionable education and feedback to providers regarding clinical documentation, diagnosis coding, E/M level assignment, and billing practices. The CDS collaborates with CDI leadership, clinical documentation colleagues, coding teams, and other organizational partners to improve documentation practices and support compliant patient care and reimbursement.

Essential Job Functions

• Identifies opportunities to recapture previously documented HCC conditions and identify potential new or “suspect” conditions supported by appropriate clinical indicators and the patient’s medical record. These reviews support accurate patient risk profiles and associated healthcare resource utilization.
• Evaluates E/M encounters to identify opportunities related to medical decision-making, patient acuity, E/M level assignment, diagnosis capture, and HCC documentation.
• Delivers individualized and group education to providers based on findings from pre-visit and post-claim reviews, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Collaborates with Professional Fee CDI leadership, CDI and coding teams, and other organizational partners to support program objectives, coordinate initiatives, and foster effective teamwork.
• Uses performance, outcome, and other available data to identify high-priority providers, specialties, encounter types, workflow opportunities, and educational needs.
• Supports the development, implementation, and evaluation of Professional Fee CDI workflows, processes, education schedules, and program initiatives.
• Identifies opportunities to clarify the medical record in a compliant and non-leading manner, consistent with applicable coding, documentation, query, regulatory, and organizational guidelines.
• Creates and delivers specialty-specific education and ongoing feedback based on chart review findings, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Communicates effectively with providers, CDI team members, coding, compliance, and other stakeholders through individual consultations, provider meetings, department or specialty sessions, and other appropriate forums.
• Maintains current knowledge of CMS requirements, official coding guidelines, HCC models, risk adjustment principles, E/M guidelines, clinical documentation requirements, and applicable industry standards.
• Maintains confidentiality in accordance with HIPAA and applicable privacy and security requirements; follows organizational policies and procedures; demonstrates professionalism and respect in all interactions; and pursues ongoing professional growth and development.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Certifications

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources

Notes

• Must hold an unencumbered nursing license prior to start.

Work Experience

• Required: A minimum of 2 years Related Experience

Language Requirements

This position requires proficiency in reading, writing, and speaking English to ensure effective communication in the workplace and with patients, families, and team members.

Physical Demands

• Sit: Frequently (34-66%)
• Stand: Occasionally (5-33%)
• Walk: Occasionally (5-33%)
• Stoop/Bend: Rarely (1-4%)
• Reach: Frequently (34-66%)
• Crawl: Not Applicable
• Squat/Crouch/Kneel: Rarely (1-4%)
• Twist: Occasionally (5-33%)
• Handle/Finger/Feel: Continuously (67-100%)
• See: Continuously (67-100%)
• Hear: Continuously (67-100%)

Weight Demands

• Lift -Floor to Waist Level: Sedentary (<10 pounds)
• Carry: Sedentary (<10 pounds)
• Push/Pull: Sedentary (<10 pounds)
• Slide/Transfer: Not Applicable

Working Conditions

• Indoor: Continuously (67-100%)
• Outdoor: Not Applicable
• Extreme Temperature: Not Applicable

Driving Requirement Definitions

• Professional Drivers: Persons who drive as their main responsibility OR transport passengers or hazardous materials.
• Frequent Drivers: Persons whose main responsibility is not driving, but drive daily or almost daily.
• Occasional Drivers : Persons who drive from once per month to as frequently as once per week.
• Infrequent Drivers: Persons who are generally not expected to drive.

Driving Requirement for this position

Infrequent Driver

Reference ID: R8450

Making a real difference. For one another.

To take the best care of our patients and community - including friends, family, and neighbors - we need people who are committed to growth, excellence, and one another.

At Altru, you’ll find a culture where support and teamwork are at the heart of what we do. You’ll have opportunities to advance your skills, work with the latest technologies, experience the fulfillment that comes from giving back, and take your career wherever you want it to go.

Join our team and be a part of a small community with a big heart.

Altru offers a comprehensive benefits package to its full- and part-time employees. Excellent benefits include a health plan and 401(k) retirement plan. Other benefits include a dental plan, vision plan, life and disability insurance, education assistance, paid time off (PTO)

Where you can work from

This job is 100% remote, for applicants who live in the United States.