Clinical Documentation Coordinator

Job Description

Job Description

Clinical Documentation Coordinator
*THIS POSITION IS NOT REMOTE*
Location: Las Vegas, NV
Employment Type: Full-Time
Work Model: Hybrid after 6-month probationary period

Position Summary

We are seeking a Clinical Documentation Coordinator to support accurate, complete, and compliant clinical documentation within an acute care inpatient setting.

The CDI Specialist will collaborate with physicians, nursing staff, coding professionals, and ancillary departments to ensure documentation reflects the severity of illness, risk of mortality, quality metrics, and reimbursement accuracy.

This position is open to qualified Registered Nurses, International Medical Graduates (Physicians), and Health Information Management professionals with required CDI certification.

Key Responsibilities

• Conduct concurrent review of inpatient medical records to ensure accurate and complete clinical documentation
• Identify documentation opportunities and initiate compliant physician queries
• Ensure documentation supports appropriate MS-DRG, APR-DRG, and risk adjustment capture
• Collaborate with Coding, Case Management, and Quality teams
• Educate providers on documentation best practices and regulatory requirements
• Monitor and improve key CDI metrics (query rate, response rate, agreement rate, CMI impact)
• Maintain compliance with CMS and payer guidelines

Minimum Qualifications

All candidates must hold one of the following CDI certifications :

• Certified Clinical Documentation Specialist (CCDS)
• Certified Clinical Documentation Specialist-Outpatient (CCDS-O)
• Certified Document Improvement Practitioner (CDIP)

Registered Nurse Pathway

Education & Experience

• Graduate of an accredited school of nursing
• Minimum 3 years of clinical nursing experience
• Minimum 3 years of Clinical Documentation Improvement experience

Licensure

• Active, unrestricted Nevada Registered Nurse license

Physician (International Medical Graduate) Pathway

Education & Experience

• International Medical Graduate (MD)
• Minimum 3 years acute care clinical experience
• Minimum 3 years CDI experience

HIM / Coding Pathway

Education & Experience

• Bachelor’s degree in Healthcare or related field (or equivalent experience)
• Minimum 3 years Health Information Management experience in acute inpatient setting
• Minimum 3 years CDI experience

Required Coding Certification (one of the following):

• Certified Coding Specialist (CCS)
• Registered Health Information Technician (RHIT)
• Registered Health Information Administrator (RHIA)
• Certified Professional Coder (CPC)
• Certified Professional Coder-Physician-based (CPC-P)

Why Join Us?

• Collaborative, team-focused CDI environment
• Opportunity to impact quality metrics and patient outcomes
• Competitive compensation based on experience and credentials

Benefits

• Employer-Paid Pension through Nevada PERS (vested after 5 years)
• Health, Dental & Vision Insurance — employee-only coverage under $20 per paycheck
• Consolidated Annual Leave (CAL): PTO, holidays (12/year), sick time, and personal leave
• Extended Illness (Sick) Bank
• 457 Deferred Compensation Plan
• Comprehensive Group Health Insurance
• No Nevada State Income Tax
• No Social Security (FICA) deduction