Clinical Documentation Specialist

Clinical Documentation Specialist

The Clinical Documentation Specialist serves as the hospital's subject matter expert for clinical documentation integrity, electronic health record (EHR) optimization, and clinical workflow design. This role bridges clinical operations, quality, regulatory compliance, health information management, and information technology to ensure accurate, complete, compliant, and efficient documentation within the EHR. The Specialist collaborates with physicians, nursing, ancillary departments, IT, and external vendors to optimize system functionality, support CMS and TJC requirements, and maintain clinical documentation integrity.

Essential Duties and Responsibilities:

• Conduct concurrent and retrospective documentation review to ensure completeness, regulatory compliance, and accurate reflection of patient severity and services rendered.
• Communicate documentation clarification opportunities to providers and collaborate with HIM on coding and DRG alignment.
• Monitor provider documentation compliance, including unsigned orders and required regulatory elements.
• Educate clinical staff on documentation standards and regulatory updates.
• Serve as the primary clinical lead for EHR build, maintenance, and workflow design.
• Develop, test, and maintain clinical documentation tools, forms, order sets, templates, and reporting structures.
• Troubleshoot system issues and coordinate resolution with IT and vendor partners.
• Manage user access, security roles, and clinical system configurations
• Provide onboarding and ongoing training for clinical users.
• Support and monitor performance for Promoting Interoperability, eCQMs, MIPS, and other CMS reporting programs.
• Support patient portal functionality and interoperability initiatives.
• Coordinate with external entities and vendors to maintain accurate provider mapping and electronic data exchange.
• Open and manage vendor support tickets as needed.
• Participate in regulatory readiness, quality improvement, and patient safety initiatives.
• Serve as a liaison between clinical departments, quality, HIM, and IT to ensure alignment of documentation and workflow practices.
• Support a culture of safety through proactive monitoring of documentation and workflow risks.
• Support CareWeb access and troubleshoot user issues.
• Build and maintain ad hoc report templates

• Ensures patient care environments and practices support exemplary, safe, and high-quality care of patients and families.
• Ensures that workplace environments are safe and that strategies are in place to prevent physical and psychological harm.
• Demonstrates clear ownership of workplace and patient safety.
• Reports mistakes, near misses, adverse events and quality and safety concerns.
• Develops and implements safety and quality plans that support exemplary workplace and care practices, while also supporting a culture of safety.
• Other duties as may be assigned.

Job Requirements

Education: Associate or Bachelor's degree in Nursing, Healthcare Administration, Health Information Management, Clinical Informatics, or related field; or equivalent combination of education and experience.

Experience: Minimum three (3) years of acute care clinical experience required. Experience in clinical documentation improvement, quality management, informatics, utilization review, or coding preferred. Experience with hospital-based EHR systems strongly preferred.

• Advanced proficiency in EHR systems and reporting tools.
• Strong analytical, problem-solving, and communication skills.
• Ability to balance regulatory compliance, reimbursement integrity, workflow efficiency, and patient safety.

Physical Requirements: Frequent sitting, standing, and walking. Ability to lift up to 25 pounds unassisted. Adequate vision and hearing for effective communication and computer-based work.