Clinical Documentation Specialist II

Summary

GENERAL SUMMARY:

Enhances the quality and integrity of clinical documentation through advanced review, analysis, and provider engagement. Conducts second-level reviews to identify opportunities to improve documentation accuracy, severity capture, and reimbursement outcomes. Provides education and feedback to clinical documentation and provider teams while supporting compliance with coding and regulatory standards. Drives documentation improvement initiatives that strengthen data quality and organizational performance.

PRINCIPAL JOB FUNCTIONS:

• Commits to the mission, vision, beliefs and consistently demonstrates our core values.
• Conducts concurrent and post-discharge second-level reviews toidentifydocumentation improvement opportunities.
• Analyzesrecords to ensureaccuraterepresentation of severity of illness, risk of mortality, and DRG assignment.
• Queries providers to clarify and enhance clinical documentation supporting patient diagnoses and care.
• Collaborates with cross-functional partners to ensure accurate and compliant medical records.
• Provides education and feedback to staff and providers on documentation, coding, and reimbursement practices.
• Maintains and analyzes trends from second-level review findings toidentifyimprovement opportunities.
• Recommends updates to review criteria and documentation practices based on audit findings and regulatory changes.
• Develops and delivers training materials to support documentation quality and compliance.
• Participates in cross-functional initiatives, committees, and projects to enhance documentation integrity.
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Participates in meetings, committees and department projects as assigned.

Performs other related projects and duties as assigned. (Essential Job functions are marked with an asterisk “*”).

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

Knowledge of diagnostic testing, surgical procedures, diseaseprocess,and care paths. Knowledge of Inpatient Prospective Payment System (IPPS), CodingRegulations,and documentation requirements. Knowledge of computer hardware equipment and software applications relevant to work functions. Knowledge of anatomy, physiology, pharmaceuticals, medical terminology, diseaseprocess,and ICD-10-CM. Skill in coaching and educating peers and physicians. Ability toestablishand maintain effective working relationships with all levels of personnel, medical staff, ancillarydepartments,and volunteers. Ability to prioritize work demands and work with minimal supervision Ability to communicate effectively both verbally and in writing Ability to maintain confidentiality relevant to sensitive information and HIPAA guidelines Ability to meet high standards for work accuracy and productivity Ability tomaintainflexibility andprioritizedaily responsibilities. Ability to maintain regular and punctual attendance. Ability to follow policies and procedures that meet the regulatory guidelines for Clinical Documentation Integrity. Ability to work independently in a time-oriented environment.

EDUCATION AND EXPERIENCE:

Graduate of an accredited nursing program required. Minimum of three (3) years of clinical documentation integrity (CDI) experiencerequired. Minimum of two (2) years of direct patient care experience in an acute care settingrequired.

OTHER CREDENTIALS / CERTIFICATIONS:

Current Registered Nurse (RN) license from the state of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Actrequired. Certified Clinical Documentation Specialist(CCDS) preferred.

PHYSICAL REQUIREMENTS:

• Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)
• DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.

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