Clinical Documentation Specialist (Inpatient CDS)

Job Title: Clinical Documentation Specialist (Inpatient CDS)



Location: Phoenix, AZ 85008



Work Setting: Remote



Start Date: October 19, 2026



Contract Length: 26 weeks



Shift: Day Shift, 5x8 hours (08:00 AM 05:00 PM)



Schedule: Full-time, day shift; hours are flexible within the day-shift window



Pay Rate: $67.00/hour

Specialty: Clinical Document Improvement Specialist

Position Overview

Valleywise Health Medical Center is seeking an experienced Inpatient Clinical Documentation Specialist (CDS) to support clinical documentation improvement initiatives.

The Clinical Documentation Specialist, under the direction of the Clinical Documentation Improvement Supervisor, uses clinical and nursing knowledge of documentation requirements to improve the overall quality and completeness of patient medical records on a concurrent basis.

The CDS works collaboratively with physicians, coding, ancillary staff, and other hospital departments to ensure clinical information in the medical record is present, accurate, complete, and appropriately reflects the patient's severity of illness and risk of mortality.

Ideal Candidate

The ideal candidate is a highly experienced CDS with a strong clinical background, preferably including critical care nursing experience .

Experience with the following is highly preferred:

• APR-DRG

• Mortality

• HACs/PSIs

• Trauma

• Burn

• Pediatrics

• NICU

• Epic

• 3M/Solventum Encoder

Minimum Requirements

• 5+ years of current CDI experience preferred/required for the position

• Inpatient Clinical Documentation Improvement experience

• Epic experience

• 3M/Solventum Encoder experience

• Strong clinical knowledge and critical-thinking skills

• Experience working collaboratively with physicians and coding teams

Key Responsibilities

• Review inpatient medical records concurrently to identify opportunities for improved clinical documentation.

• Work collaboratively with physicians and providers to ensure clinical information is accurately documented.

• Formulate appropriate provider queries when additional documentation specificity is needed to clarify, link, or establish diagnoses, conditions, and procedures.

• Support appropriate representation of severity of illness and risk of mortality in collaboration with Coding.

• Provide education to physicians and ancillary staff regarding clinical documentation clarification.

• Collaborate with hospital departments to support medical necessity, admission requirements, continuity of patient care, and other clinical documentation requirements.

• Analyze and benchmark clinical documentation program performance.

• Apply knowledge of coding, DRG assurance, revenue cycle, MS-DRGs, APR-DRGs, and related processes.

Knowledge, Skills & Abilities

• Exceptional critical-thinking and communication skills.

• Strong clinical knowledge base.

• Effective interpersonal skills for interacting with providers.

• Strong analytical skills to interpret medical record documentation and formulate appropriate provider queries.

• Knowledge of anatomy and physiology, pathophysiology, and pharmacology.

• Knowledge of AHA Coding Clinic and AHIMA Query Practice Brief guidelines.

• Knowledge of MS-DRGs, APR-DRGs, DRG assurance, Coding, Revenue Cycle, and Midas .

• Ability to benchmark and analyze clinical documentation program performance.

• Basic computer and word-processing skills, including formatting, editing, printing, composing email, internet searches, and navigating electronic medical records.

• Ability to read, write, and communicate effectively in English.

Education

Required:

• Associate's degree in Nursing, Health Information Technology, or a related field; OR

• Equivalent combination of training and progressively responsible experience resulting in the required specialized knowledge and abilities.

Preferred:

• Bachelor's degree in Nursing

• Bachelor's degree in Health Information Administration

• Related bachelor's degree

Experience

The position requires a minimum of three (3) years of recent clinical nursing, coding, or clinical documentation experience demonstrating an understanding of the required knowledge, skills, and abilities.

For this specific Inpatient CDS opening, a minimum of 5 years of current CDI experience is preferred/required per the job overview.

Certification / Licensure

Candidate must possess one of the following:

• Current, valid Arizona RN or LPN license

• Valid Compact RN or LPN license for the current state of practice

• RHIA

• RHIT

• CCS

• CCS-P

• CPC

• CIC

• COC

Preferred Certification:

• Certified Clinical Documentation Specialist ( CCDS )

Additional Facility Information

COVID-19 Vaccine: Not Required



Flu Vaccine: Required Medical/Religious exemptions only



Block Schedule: No



On-Call: None specified



Orientation: All hours billable

Contract Duration: 26 weeks, with the job overview indicating a potential 6 9 month engagement.

Why Consider This Opportunity?

• Full-time inpatient CDI position

• Remote work setting

• Day-shift schedule

• Opportunity to work with a multidisciplinary clinical documentation team

• Focus on complex inpatient documentation, severity of illness, and risk of mortality

• Experience with Epic and 3M/Solventum Encoder valued

• Critical care, Trauma, Burn, Pediatrics, and NICU experience preferred