Clinical Documentation Specialist (2026-0737)

Job Title: Clinical Documentation Specialist Req: 2026-0737 Location: VMC Main Campus Department: Health Information Mgmt Shift: Days Type: Full Time

FTE: 1

City State: Renton, WA Category Professional ( NCNM) Salary Range: Min $94,894 - Max $142,341/annual DOE JOB DESCRIPTION The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization. TITLE: Clinical Documentation Specialist RN JOB OVERVIEW: The Clinical Documentation Specialist provides an essential role in ensuring the medical record accurately reflects the patient’s clinical condition, severity of illness, risk of mortality, quality outcomes, and services provided. The position serves as a liaison between providers, coding professionals, case management, quality, and revenue cycle teams to improve documentation accuracy, support complete coding and billing compliance. DEPARTMENT: Health Information Management WORK HOURS: Monday - Friday, typically 7:00 AM - 3:30 PM. Flexibility may be required to meet department and organization needs. REPORTS TO: Manager, Clinical Documentation Improvement Prerequisites: Current unrestricted Registered Nurse (RN) license in the State of Washington, required. Minimum five years recent clinical experience as a Registered Nurse in an acute care inpatient hospital setting, OR minimum of three years of acute care inpatient hospital setting combined with at least one year of inpatient Clinical Documentation Specialist experience, required. Certified Clinical Documentation Specialist (CCDS) strongly preferred Clinical Documentation Specialist - Outpatient (CCDS-O) strongly preferred. Experience In EPIC (Resolute) Or Similar EHR Required. Proficient in various computer applications, including Microsoft Office, Excel, Word, PowerPoint, Visio, and Outlook. Qualifications: Understanding of MS-DRGs, APR-DRGs, Severity of Illness (SOI), Risk of Mortality (ROM), Hierarchical Condition Categories (HCCs), and value-based reimbursement methodologies. Proven ability to build collaborative partnerships with physicians and departments to drive organizational initiatives. Exceptional organizational and self-management skills, with the ability to prioritize, multitask, and manage multiple projects effectively in a fast-paced, deadline-driven environment. Effective communicator with ability to facilitate discussions and present clearly to groups. Ability to remove technical and cultural barriers to achieve operational objectives. Comprehensive knowledge of disease processes, clinical terminology, anatomy, and physiology. Familiarity with compliant physician query practices and clinical validation principles. Comprehensive knowledge of industry standards, regulatory requirements, and best practices to ensure successful project delivery in alignment with departmental objectives. Excellent organizational and interpersonal skills, including the ability to work collaboratively across departments, in a matrix environment with colleagues at all levels of the organization to achieve strategic goals. Ability to effectively communicate using verbal, written and presentation form. Self-motivated and results oriented. Demonstrate critical thinking, clinical judgment, problem-solving, and deductive reasoning skills. Unique Physical/Mental Demands, Environment And Working Conditions: Must possess ability to work independently, with minimal direction, and take initiative in problem solving. Must be able to interact professionally and effectively with a wide variety of people, including operations staff, providers, the general public, and departments at Valley Medical Center (VMC). Attention To Detail And Excellent Organizational Skills Are Essential. Must be able to function effectively in an environment with frequent interruptions and multiple tasks. Must be able to effectively interact with patient access and billing systems and other relevant third-party software, create, and maintain spreadsheets, and take and compose meeting minutes. Requires manual and finger dexterity and vision corrected to normal range. Requires prolonged periods of sitting and prolonged exposure to computer monitor and keyboarding. Performance Responsibilities: Generic Job Functions: See Generic Job Description for Administrative Partner. Essential Responsibilities and Competencies Conduct comprehensive reviews of electronic medical records (EMRs) to ensure documentation is complete, accurate, and clinically supported, with appropriate reflection of severity of illness (SOI), risk of mortality (ROM), quality indicators, and documentation integrity, utilizing approved Clinical Documentation Integrity (CDI) methodologies and documentation strategies. Conduct accurate, timely concurrent and retrospective medical record reviews in accordance with established departmental standards to ensure documentation supports the patient’s clinical condition, quality outcomes, and compliant coding practices. Assign a working APR-DRG and severity level utilizing applicable coding rules and guidelines and conduct follow-up reviews according to established length-of-stay (LOS) standards. Collaboratively resolve CDI-coder DRG discrepancies in accordance with established reconciliation processes. Analyze clinical information to identify documentation gaps, inconsistencies, and opportunities for documentation improvement. Identify opportunities to improve physician documentation related to principal diagnoses, secondary diagnoses, comorbidities, complications, present-on-admission (POA) indicators, quality measures, and patient safety indicators (PSIs). Develop and communicate clinically supported, industry-standard documentation clarification queries that promote accurate, complete, and compliant clinical documentation to include: principal diagnoses comorbidities Present on Admission (POA) indicators quality measures patient safety indicators regulatory requirements Utilize established workflows and communication processes to effectively collaborate with physicians and interdisciplinary care teams regarding documentation opportunities. Identify barriers to achieving documentation improvement goals and implement appropriate interventions. Timely follow up on all cases requiring clinical documentation clarification and ensure resolution in accordance with departmental processes. Work with the CDI Manager to resolve documentation discrepancies, clinical validation concerns, and escalation issues to ensure timely provider responses. Maintain proficiency of applicable coding, reimbursement, and regulatory guidelines in accordance with organizational and industry standards. Provide education and guidance to physicians, advanced practice providers, coding staff, and other healthcare professionals regarding documentation requirements and improvement opportunities. In collaboration with CDI leadership, participate in education initiatives for physicians, providers, CDI staff, and coding staff regarding documentation regulations, coding guidelines, quality measures, audit findings, and documentation improvement opportunities. Meet established productivity, quality, and performance standards upon completion of training. Demonstrate the ability to learn and develop the competencies necessary to perform job responsibilities and achieve departmental goals. Participate in the orientation, training, and onboarding of new CDI staff members. Engage and participate in organizational initiatives, performance improvement activities, and interdisciplinary projects that support documentation quality and organizational goals. Demonstrate awareness of cost containment principles and identify opportunities for process improvement, quality enhancement, and operational efficiency. Maintain working knowledge of clinical documentation integrity practices, coding conventions and guidelines, reimbursement methodologies, and regulatory requirements. Maintain ongoing professional development and educational activities through participation in relevant professional organizations. Adhere to all hospital policies, procedures, and standards of conduct. Maintain confidentiality of all protected health information in accordance with applicable regulations and organizational policies. Perform all job responsibilities in a manner consistent with Valley Values, including quality, compassion, respect, teamwork, community-centered service, and innovation. Perform other duties as assigned to support the accurate, compliant, and efficient operation of the revenue cycle and organization. Date Created: 5/18 Revised: 7/22, 7/26 Grade: NC-11

FLSA: E

Cost Center: 8490 Qualifications: Understanding of MS-DRGs, APR-DRGs, Severity of Illness (SOI), Risk of Mortality (ROM), Hierarchical Condition Categories (HCCs), and value-based reimbursement methodologies. Proven ability to build collaborative partnerships with physicians and departments to drive organizational initiatives. Exceptional organizational and self-management skills, with the ability to prioritize, multitask, and manage multiple projects effectively in a fast-paced, deadline-driven environment. Effective communicator with ability to facilitate discussions and present clearly to groups. Ability to remove technical and cultural barriers to achieve operational objectives. Comprehensive knowledge of disease processes, clinical terminology, anatomy, and physiology. Familiarity with compliant physician query practices and clinical validation principles. Comprehensive knowledge of industry standards, regulatory requirements, and best practices to ensure successful project delivery in alignment with departmental objectives. Excellent organizational and interpersonal skills, including the ability to work collaboratively across departments, in a matrix environment with colleagues at all levels of the organization to achieve strategic goals. Ability to effectively communicate using verbal, written and presentation form. Self-motivated and results oriented. Demonstrate critical thinking, clinical judgment, problem-solving, and deductive reasoning skills. #J-18808-Ljbffr Valley Medical Center & Clinics