Inpatient CDS/Clinical Documentation Specialist

Position Summary

We are seeking an experienced Inpatient Clinical Documentation Specialist (CDS) to support clinical documentation improvement initiatives. The ideal candidate will have a strong clinical background, preferably in critical care nursing, and extensive experience in inpatient CDI, physician query development, and clinical documentation review.

The CDS will work collaboratively with physicians, coding professionals, and multidisciplinary teams to ensure accurate, complete, and compliant clinical documentation. The position focuses on improving severity of illness (SOI), risk of mortality (ROM), appropriate DRG assignment, and overall documentation quality.

Key Responsibilities

• Conduct concurrent inpatient clinical documentation reviews to ensure accuracy, completeness, and clinical consistency of medical records.
• Identify opportunities for improved documentation specificity, clinical clarification, and accurate diagnosis reporting.
• Develop and issue compliant physician queries based on clinical indicators and documentation gaps.
• Collaborate with physicians, nurses, coding professionals, and other healthcare teams to improve documentation quality.
• Support accurate MS-DRG and APR-DRG assignment, severity of illness, and risk of mortality reporting.
• Review and identify opportunities related to mortality reviews, Hospital-Acquired Conditions (HACs), and Patient Safety Indicators (PSIs).
• Ensure clinical documentation supports medical necessity, patient admission, continuity of care, and reimbursement requirements.
• Provide physician education regarding documentation standards, clinical indicators, and compliant query practices.
• Apply AHA Coding Clinic and AHIMA Query Practice Brief guidelines when reviewing documentation and formulating queries.
• Analyze CDI program performance, identify trends, and support documentation improvement initiatives.
• Work collaboratively with Coding and Revenue Cycle teams to support appropriate reimbursement and clinical accuracy.
• Maintain compliance with organizational policies, regulatory requirements, and documentation standards.

Required Qualifications

• Minimum 5 years of recent/current inpatient Clinical Documentation Improvement (CDI) experience.
• Current and valid RN certification/licensure with CCDS certification preferred or required as specified by the client.
• Strong clinical knowledge, preferably with a critical care nursing background.
• Experience with inpatient clinical documentation review, physician queries, and DRG assurance.
• Strong knowledge of MS-DRG and APR-DRG methodologies.
• Experience with severity of illness (SOI), risk of mortality (ROM), mortality reviews, HACs, and PSIs.
• Epic experience is required.
• Experience with 3M/Solventum encoder systems is required.
• Strong knowledge of anatomy, physiology, pathophysiology, pharmacology, and clinical coding principles.
• Knowledge of AHA Coding Clinic and AHIMA compliant query guidelines.
• Excellent analytical, critical-thinking, communication, and interpersonal skills.
• Ability to work independently in a remote environment and collaborate effectively with physicians and multidisciplinary teams.

Preferred Qualifications

• Critical care nursing experience.
• Experience in Trauma, Burn, Pediatrics, and Neonatal Intensive Care Unit (NICU) documentation.
• Experience with Midas and DRG assurance.
• Bachelor's degree in Nursing, Health Information Administration, or a related field.
• CCDS certification.

Education & Licensure

• Associate's degree in Nursing, Health Information Technology, or a related field, or an equivalent combination of education and experience.
• Bachelor's degree in Nursing or Health Information Administration preferred.
• Current, valid Arizona RN/LPN license or compact RN/LPN licensure for the state of practice; alternatively, an applicable credential such as RHIA, RHIT, CCS, CCS-P, CPC, CIC, or COC, as accepted by the client.
• CCDS certification preferred.

AlphaProTemps is specialized in providing "best-in-class" professional staff augmentation services. These recruiting directives include temporary labor, contract sourcing, professional & technical niches, vendor-on-site, and managed service programs.