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.