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.