Job Board

Welcome to the ACDIS Job Board!

ACDIS member organizations may post up to two openings per year. You must login to access the form. Additional job postings may be made available for a fee.

Non-ACDIS members can post openings for a fee of $350 per job description by contacting ACDIS member relations at, or by phone at 800/650-6787.

Each post will remain on the board for roughly 30 days.

Job description and benefit language must be limited to the actual job description and benefits, without extraneous language about the facility or region.

There is a character limit of 1,500 for description and 700 for benefits (including spaces and punctuation). We will edit your post (or return for you to edit) if the counts exceed the stated limits.

Date of Request: March 4, 2105
Job Title:  Clinical Documnetation Improvement (CDI) Manager (Job ID #1135047)
Name of Facility/Hospital: Barnes-Jewish Hospital
Location of Facility/Hospital: St. Louis, MO
Contact Person/email/phone: 
Contact Address:

Job Description: Will manage the clinical documentation improvement program by identifying opportunities for improvement through report-analysis interpretation of process & operational reports, financial and compliance reports, and quality-ratings reports. This individual will assist with various associated operational matters, including scheduling and coverage of review, query development & auditing, educating physicians, monitoring the program, and refining the process to clarify documentation.

  • Associate's degree
  • Current MO RN license
  • Five or more years of related experience, including two or more in a supervisory capacity
  • Bachelor's degree in nursing

To learn more and apply, go to: and search using job ID number listed above.

To learn more about Barnes-Jewish Hospital, visit
Equal Opportunity Employer

Compensation: Not Specified
Benefits: Not Specified
Preferred Start Date:  Not Specified
Position Type: Full-time


Date of Request: March 5, 2015
Job Title: Supervisor - Clinical Documentation Excellence (RN)
Name of Facility / Hospital: Mercy
Location of Facility / Hospital: Lorain, Ohio
Contact Person: Judy Heikkinen
Contact Address:

Job Description: Oversees site-based Clinical Documentation Excellence (CDE) program; monitors and maintains the timeliness of workflow, productivity, and quality of the site CDE program; develops and monitors implementation of site departmental goals/objectives.  Ensures staff competency by conducting on-going reviews and skills assessments; provides action plans and timely constructive feedback to enhance staff development; leads hiring, training and performance management processes for all site-based CDE employees. Develops ongoing documentation improvement education programs based on regulatory changes or updates and internal quality audits for site CDS, administration and physicians.  Is direct contact for the physician advisor. Is contact in the absence of the Clinical Documentation Manager. 

Associate degree in Nursing required; Bachelor’s preferred.  Current RN license in the state of Ohio; current CCDS (Certified Clinical Documentation Specialist) certification or willingness to obtain certification within one year of role acceptance.  At least five years of nursing experience in either Med/Surg, Intensive Care, or Emergency Department. At least one year of experience as a Clinical Documentation Specialist, self-motivated, strong organizational skills, excellent speaking and presentation skills.  Willingness to update technical expertise and to develop management/leadership skills through continuing education throughout tenure in position, and to travel within the market.

Preferred Start Date: March 5, 2015
Position Type: Full-time


Date of Request: March 4, 2015
Job Title: Clinical Documentation Specialist
Name of Facility / Hospital: Jacobi Medical Center
Location of Facility / Hospital: Bronx, NY
Contact Person: Carol O'Connor - Assistant Director
Contact Address:

Job Description: We are looking for seasoned Clinical Documentation Specialists to join our Clinical Documentation Management Team. The successful candidates will facilitate the improvement in the quality, completeness, and accuracy of medical record documentation to reflect the level of service rendered to our patients. You will obtain and promote the appropriate clinical documentation through extensive interaction with the physicians, nursing staff and Health Information Management Coders. It will be your responsibility to educate the physicians regarding documentation guidelines on an ongoing basis. Excellent communication, analytical and interpersonal skills are essential. Requirements include:

  • Valid NYS Registered Professional Nurse License
  • BSN, Master's preferred
  • Registered Physician Assistant or Foreign Medical Graduate will be considered
  • A minimum of five years of recent medical-surgical nursing experience
  • Computer literacy including working knowledge of Microsoft Word and Excel
  • Knowledge of DRG reimbursement or previous Clinical Documentation improvement experiences a plus

These positions are in the managerial class and work a 35-hour workweek, specific hours are 7:30 am to 3:30 pm, Monday through Friday. Qualified candidates, please mail, email or fax your resume, including salary history and requirements to: Carol O’Connor, Assistant Director of Clinical Documentation Improvement Management, North Bronx Healthcare Network, Jacobi Medical Center, Building 1 Room 4S3, 1400 Pelham Parkway South, Bronx, NY 10461

Compensation: Competitive
Benefits: Competitive compensation package effective date of hire
Preferred Start Date: April 1, 2015
Position Type: Full-time

Date of Request: March 2, 2015
Job Title: CDI Specialist
Name of Facility / Hospital: Confidential
Location of Facility / Hospital: Albuquerque, NM
Contact Person: Delma Beltran
Contact Address:

Job Description:
ProHealth Staffing has a great opportunity for a temp to hire or full-time position for a CDI Specialist in Albuquerque, New Mexico. The Clinical Documentation Improvement (CDI) Specialists works collaboratively with medical staff, nursing staff, other healthcare professionals, and coding staff to ensure accurate capture of clinical information through chart review, querying, and education. Qualifications: -Prefer Knowledge of McKesson Star and HPF and/or Siemens/Soarian EDM -Minimum 3+ years of experience in coding and/or clinical setting -Licensed Registered Nurse, BSN preferred or RHIA or RHIT or CCS or Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) is preferred. Please call Delma @ (855) 747-4473 or email at

69K+ or DOE
Preferred Start Date: March 2, 2015
Position Type: Full-time , Permanent , Contract

Date of Request: March 2, 2015
Job Title: Clinical Documentation Specialist
Name of Facility / Hospital: Tanner Health System
Location of Facility / Hospital: West Georgia - Carrollton, Villa Rica, Bremen
Contact Person: Vette Carr
Contact Address:

Job Description: We seek: RHIA, RHIT, CCS, CPC, or RN with 2+ years as a full-time clinical documentation specialist; or RHIA or RHIT with CCS or CPC credential with 2+ years acute care inpatient coding experience; or RHIA or RHIT without coding credential with 3+ years acute care inpatient coding experience; or RN with 5+ years recent adult ICU or adult medical-surgical experience. The clinical documentation specialist: Reviews the assigned medical record for documentation that is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent, that describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis, that includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure, that provides a diagnosis without underlying clinical validation, or is unclear for present on admission indicator assignment.

  • Queries providers as needed to obtain clarification of documentation, in accordance with departmental query policy. Assigns working DRG during concurrent review, revises the working DRG as appropriate, and reconciles the working DRG with the final DRG assigned by the HIM coding team after discharge. Delivers multifaceted education to providers regarding relevant issues and topics in clinical documentation.
  • Participates in projects and tasks related to clinical documentation, as directed.

Compensation: Salary commensurate with experience.
Benefits: Competitive benefits
Preferred Start Date: March 2, 2015
Position Type: Full-time

Date of Request: February 26, 2015
Job Title:  Continuous Clinical Documentation Improvement Specialist (CQI/CDI)
Name of Facility/Hospital: Holy Redeemer Health System
Location of Facility/Hospital: Meadowbrook, PA
Contact Person/email/phone:  Human Resources/
Contact Address: Meadowbrook, PA 19046

Job Description:
Continuous Clinical Documentation Improvement Specialist (CQI/CDI) Holy Redeemer is seeking a CQI CDI Specialist responsible for coordinating all aspects of care provided to a defined patient population relating to specific quality/safety initiatives. This individual will be responsible for the collection, evaluation and reporting of related quality improvement, risk management and safety activities as identified by departmental/service leadership, system strategic imperatives and regulatory requirements. Also, be responsible for generating and evaluating statistical reports directed toward continuous improvement of the quality and safety of patient care and working with others to reduce risk and improve compliance with quality indicators by assisting in the development of preventative and corrective plans of action.
Bachelor’s Degree preferred. Registered Nurse with 3-5 years clinical experience in acute care required. Thorough knowledge of quality/performance improvement principles and tools preferred. Experience with facilitating quality and safety assessment and improvement activities preferred. Previous experience in inpatient coding required or sufficient knowledge of clinical documentation, DRG assignment and clinical conditions or procedures. Highly prefer previous quality improvement experience working with physician groups.

To apply, please visit
Equal Opportunity Employer

Compensation: DOE
Preferred Start Date: TBD
Position Type: Full-Time


Date of Request: February 26, 2015
Job Title: Corporate CDI $120K - $140K up to 20% bonus incentives
Name of Facility / Hospital: Continuous Quality Improvement Executive Search
Location of Facility / Hospital: Nashville, TN
Contact Person: Carolyn Lee
Contact Address:

Job Description: Provides remote and onsite support of clinical documentation improvement activities in an effort to support accuracy and quality in the patient records at hospital facilities and to ensure that coded diagnoses are an accurate reflection of the patient's clinical status and care. The responsibilities include, but are not limited to, development and delivery of Physician, Coder and Clinical Documentation Improvement Specialist (CDIS) education through a variety of modalities, coordination of the CDI audits, support of facility-level CDIS staffing initiatives, and providing senior leadership orientation to documentation improvement activities. This individual will possess a broad knowledge of documentation requirements for accurate ICD-9-CM, ICD-10-CM/PCS and MS-DRG assignment. This knowledge will play a key role in determining the reimbursement and quality potential of hospital facilities. Adherence to official coding compliance regulations, corporate policies developed to ensure accurate billing, and industry best-practice is essential.

Required: Based in Franklin, TN. Ability to travel approximately 50% - 75% of the time. Travel required by both airplane and automobile. Must be an RN with preferred certifications: CDIP, CCDS, CCS and/or ICD-10 certification or Trainer designation. Team leadership experience in relation to CDI. Educating physicians and large groups of people in clinical documentation improvement. Must have a valid driver’s license.

Compensation: Depending on Experience & Education $120K up to $140K up to 20% bonus
Benefits: Offering full relocation package, full benefits and up to 20% bonus.
Preferred Start Date: April 6, 2015
Position Type: Full-time

Date of Request: February 25, 2015
Job Title: Clinical Documentation Improvement Specialist (CDIS)
Name of Facility / Hospital: HCA Mountain Division - Mountainstar Healthcare
Location of Facility / Hospital: Salt Lake City, Utah
Contact Person: Carma Evans

Job Description: Provides clinically based concurrent and retrospective reviews of the inpatient medical records to evaluate the documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation to ensure complete and accurate representation of the patient's clinical complexity and services rendered including severity of illness and risk of mortality. The CDIS communicates with clinicians and physicians to ensure timely and accurate documentation. The CDIS is expected to perform duties independently with little supervision. This is a full-time, benefited HCA Mountain Division position. The CDIS staff works as a centralized team within the Mountain Division and report directly to the Mountain Division Clinical Documentation Manager.
Required qualifications:

  • Current RN License or CDIP/CCDS, CCS/RHIT/RHIA eligible
  • Associates degree preferred
  • Minimum of 5 years' experience in an acute care setting as a Registered Nurse or Inpatient Coder (Critical Care, Medical/Surgical or Emergency department nursing preferred)

Apply at:

Compensation: Based on qualifications and experience
Preferred Start Date: March 25, 2015
Position Type: Full-time , Permanent

Date of Request: February 25, 2015
Job Title:  Clinical Documentation Improvement Specialist
Name of Facility/Hospital: Beverly Hospital: A Member of Lahey Health
Location of Facility/Hospital: Addison Gilbert Hospital, Gloucester MA
Contact Person/email/phone:  Leanne Francis/   
Contact Address: 133 Brimbal Ave., Suite D, Beverly, MA 01915. Apply directly to our website:

Job Description: Reviews physician documentation on a concurrent basis on selected DRG?s to ensure that severity of illness, intensity of services and risk of mortality are documented.  Ensures that documentation is complete, accurate, and substantiates the patients? diagnosis and all applicable co-morbid conditions. Works with the Director of Coding and Care Coordination to educate the medical staff regarding the importance of complete and accurate documentation, which fully describes the clinical severity of the patient to validate the DRG.  Works closely with clinical staff/departments to educate and improve the level of documentation. Prepares reports on results of audits for Administration as appropriate.

 1. Current Massachusetts RN licensure required. RHIA, RHIT, CCS a plus
1. Bachelors degree preferred
2. Minimum five(5) years experience in medical surgical nursing an two(2) years experience as a hospital CDIS

Please apply directly to our website:

Compensation: n/a
Benefits: Benefit eligible
Preferred Start Date: n/a
Position Type:  Clinical

Date of Request: February 23, 2015
Job Title:  Clinical Quality Documentation Specialist
Name of Facility/Hospital: Northwestern Memorial Hospital
Location of Facility/Hospital: Chicago, IL
Contact Person/email/phone: 
Contact Address:

Job Description: Northwestern Memorial Hospital is seeking a full-time/first-shift Clinical Quality Documentation Specialist for its downtown Chicago campus. Responsibilities include partnering with operational and medical leadership to identify, develop, and implement successful lines of communication and education, engage physicians, and improve processes/outcomes. Collaborating with the clinical quality team, clinical coding team, and medical directors to model and improve the culture of safety, this professional will make daily rounds with physicians and providers to ensure accurate documentation in the medical record, make sure that the level of services and acuity of care are accurately reflected in quality outcomes, and perform medical-record reviews. This individual will perform data-collection activities to identify issues and opportunities for improvement in patient care and services; and analyze quality and patient-safety data; present updates to leadership.

Requirements: Bachelor's of science in Nursing; current RN license for the state of Illinois; demonstrated expertise in the area of advanced clinical care; strong interpersonal, communication, conflict-management, diplomacy, and negotiation skills; proven leadership abilities that affect positive clinical quality outcomes; strong analytical skills to collect/analyze/interpret data; and basic computer proficiency. Preferred: 5+ years of experience in med/surg, critical care, intensive care or emergency care.

For more information and to apply, please visit us online at: (job # KMG20150602-01770) AA/EOE

Apply at

Benefits: Exceptional resources, education, growth opportunities, and benefits, including premier health insurance featuring our renowned physician network
Preferred Start Date:
Position Type: Full-Time

Date of Request: February 23, 2015
Job Title:  Clinical Documentation Tech – Inpatient Coding
Name of Facility/Hospital: Johns Hopkins Hospital
Location of Facility/Hospital: Baltimore, MD
Contact Person/email/phone:  N/A
Contact Address: N/A

Job Description: Johns Hopkins Hospital is currently seeking a Clinical Documentation Tech. The responsibilities of this position include:
•    Assigning all ICD9 diagnostic codes and ICD9 operative codes to each inpatient encounter.
•    Ensuring there is a complete clinical data set, and that clinical documentation supports accurate diagnoses and procedures.
•    Grouping all encounters to most appropriate APRDRG and severity level using the APRDRG coding system.

To qualify for this position, you must have a high school diploma or equivalent, a minimum of 2 (2.5) years’ internal inpatient coding experience beyond initial training period, and be CCS certified. Comprehensive knowledge of anatomy, physiology, and all body systems, and of college-level Medical Terminology, ICD-9-CM coding system and APRDRG grouping system, as well as complete understanding of the unique functions of each clinical area, is a must. The successful candidate will also have comprehensive understanding of clinical documentation standards related to departmental activities, and proficiency in abstracting and data entry into all data bases used for clinical documentation. Ability to demonstrate coding principles is essential.

Tele-commuting for coders and very flexible schedules are available once orientation and training are complete.

Please visit us at:
Refer to req. #18276


Preferred Start Date: Open
Position Type:  Full Time


Date of Request:  February 19, 2015
Job Title:  Clinical Documentation Improvement Specialist – Non Clinical
Name of Facility/Hospital:  Valley Children’s Hospital
Location of Facility/Hospital: Fresno/Madera, CA
Contact Person/email/phone:  Dennis Yee  (559) 353-7058
Contact Address: 9300 Valley Children’s Place, Madera, CA 93636
Job Description:  The HIM Clinical Documentation Improvement Specialist will assist in concurrent by assigning the appropriate diagnosis, procedures and working DRG and conducts retrospective reviews to evaluate the clinical documentation in the medical record to capture missed conditions and procedures that are supported by the clinical documentation. Performs Clinical Documentation Improvement report generation for scorecard and dashboard reporting, scorecard maintenance, and data analysis. Serves as a liason and resource for coder, Clinical Documentation Improvement Specialist-Clinical, and the documenting provider. This position requires:
  • a High School Diploma/GED. Associate's Degree or Bachelor's Degree in Health Information Management preferred;
  • CCS within 18 months of hire or CDIS certification. A RHIT or RHIA preferred; and
  • a minimum of 5 years work related experience in a Health Information Management Department or health related field.
Additional qualifications include: Strong working knowledge of coding and operational implications of ICD-10: Strong working knowledge of medical terminology, disease processes, and pathophysiology for the appropriate query and application of codes to achieve appropriate APR-DRG. Knowledge of compliance rules surrounding CDI interaction with MD's; Ability to act as a backup/SME to RN/MD to enable and encourage documentation and query process(es); Expert in writing compliant queries. Apply online at
Compensation:  Competitive salary offered including relocation assistance package
Benefits:  Comprehensive benefits package offered including medical, dental, vision, prescription plan, free life insurance and long term disability insurance, PTO (accrue 7.69 hours per pay period, 26 X 7.69 = 199.94 hours of PTO per year), two pension plans (403b with a 60% employer match of the first 6% of your compensation after first year of employment, hospital defined contribution base plan that contributes 2%, 4% or 6% of employee’s annual earnings after first year of employment), education assistance, credit union, direct deposit, vacation discounts, and pet insurance.
Preferred Start Date:  ASAP
Position Type:  Full-time


Date of Request: February 18, 2015
Job Title:  Manager, Clinical Documentation Improvement
Name of Facility/Hospital: UMass Memorial Medical Center
Location of Facility/Hospital: Worcester, MA
Contact Person/email/phone:  Adrienne Naddeo;; 508-793-5651
Contact Address:

Job Description: The Clinical Documentation Improvement Manager is responsible for the planning, implementation and ongoing maintenance of the Clinical Documentation Improvement Program.  Manages and oversees the daily operations of the program activities and staff, data collection, analysis and reports to meet department and corporate target goals.

Qualifications: Bachelor’s degree and Massachusetts licensure as a registered nurse required.  Experience in Clinical Documentation Improvement required.  Experience supervising staff strongly preferred. Position requires excellent critical thinking skills; knowledge of care delivery documentation systems and related medical record documents; broad-based clinical knowledge and understanding of pathology/pathophysiology; as well as the ability to adapt to changes in the workload, to work independently and to effectively prioritize work assignments.

Apply online at:

Preferred Start Date: 2/18/15
Position Type: full time/benefitted



Date of Request: February 16, 2015
Job Title: Clinical Documentation Specialist
Name of Facility / Hospital: Houston Methodist Hospital
Location of Facility / Hospital: Houston, Texas
Contact Person: Mary Thomas MSN, RN - Manager CDI
Contact Address:

Job Description: Job Description: Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for the Hospital. Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians advocating for appropriate reimbursement relative to the patients care, resources consumed and the level of services rendered. Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patients true severity of illness and intensity of care. Educates all members of the health care team on an ongoing basis Education: Bachelor of Nursing required Experience: At least five years recent clinical experience caring for adults in an acute care hospital setting. Coding experience is preferred. Licensure: Current Texas RN license

Compensation: Competitive and commensurate with experience
Benefits: Generous benefit package including medical, dental, vision, 403B, tuition reimbursement and more.
Preferred Start Date: March 2, 2015
Position Type: Full-time , Permanent

Date of Request: February 13, 2015
Job Title:  Compliance Auditor RN Coder
Name of Facility/Hospital: The Christ Hospital 
Location of Facility/Hospital: Cincinnati, Ohio 
Contact Person/email/phone:  Teelisha Higgins 513-263-1510
Contact Address:

Job Description: Responsible to carry out and, implement the Division of Compliance and Organizational Ethics (the “Division”) TCH System audit and education programs. Follows policies and procedures that promote the goals of the Division and facilitates effective audits, monitors and reporting to management. Maintains superior excel data base skills to assure efficiencies in production of audits and data analysis. Performs compliance risk assessments, evaluates processes for compliance effectiveness, designs audit test plans to review high risk processes and billing. Performs audits investigations and reviews, making recommendations to management on internal control and process effectiveness.  Maintains Compliance data bases and participates in education and training of physicians, employees. Is knowledgeable of applicable regulations and communicates effectively and works collaboratively with TCH stakeholders to assure compliance. Responsible for the dissemination, implementation of policies, compliance and audit standards, and department data base maintenance and tracking of compliance with the TCH CIA on a system wide basis.

The Christ Hospital is an EOE, drug-free and smoke- nicotine free environment. Dynamic, forward-thinking candidates are invited to apply at

Education: Bachelor’s degree RN required.  Coding Certification highly desired.  CHC certification required after one year on the job.

Experience: At least 5 years; healthcare management experience desired.

Compensation: $47,507.20-$78,665.00
Preferred Start Date:
February 20, 2015
Position Type: Full-time

Date of Request: February 12, 2015
Job Title: RN Documentation Improvement Specialsit
Name of Facility / Hospital: Catholic Medical Center
Location of Facility / Hospital: Manchester, NH 03102
Contact Person: Donnella Lubelczyk
Contact Address:

Job Description:
Reviews clinical documentation on inpatient admissions to identify opportunities to improve provider documentation to ensure accurate and complete coding, severity of illness and/or risk of mortality. Reviews records that may have documentation improvement opportunities and query and/or directly communicate with the physicians and providers to obtain the necessary documentation. Follows up on all cases queried until an acceptable response is received. Maintains knowledge of documentation requirements in accordance with AHA Coding Clinic, Core Measures specifications and external rating methodologies. Maintains knowledge of all outside grading company standards and guidelines and how documentation affects hospital ratings. Query physicians when necessary for complete documentation of these issues to better identify the severity of illness and risk of mortality. Educates medical staff on all documentation guidelines for coding and external healthcare rating companies about the effects on reimbursement, severity of illness and risk of mortality. Tracks all responses of queries and utilize reporting techniques for statistical purposes. Report and track all activities and outcomes of queries. Tracks all trends found for further education to the providers and the coding staff. Develops and initiates educational programs regarding proper documentation; Please visit the website for the entire job description,qualifications and experience preferred. Apply Online www.catholicmedica


Preferred Start Date: February 12, 2015
Position Type: Full-time

Date of Request: February 11, 2015
Job Title:  Clinical Documentation Specialist I – RN
Name of Facility/Hospital: Lehigh Valley Health Network
Location of Facility/Hospital: Allentown, PA
Contact Person/email/phone:  N/A
Contact Address: N/A

Job Description: As the Clinical Documentation Specialist (CDS) you will be responsible for improving the overall quality and completeness of clinical documentation in the medical records to reflect the severity of illness, clinical treatment, decisions and diagnoses of patients. This position involves concurrent medical record review as well as education and interaction with physicians, HIM Coders and others involved in the care of the patient.

To qualify, you must be a Registered Nurse with current Pennsylvania Licensure or Certified Health Information Management licensure, with at least five years’ of recent advanced clinical experience and extensive knowledge of complex disease processes in an acute care hospital setting. Two years’ experience as a Clinical Documentation Specialist (CDS) in an acute care facility with experience assigning Working DRGs based on coding guidelines and regulations issued by AHA, AHIMA, and CMS is required. CPC, CCS-P, and/or RHIT preferred. CCDS or CDIP certification preferred upon hire, but is required within 1-2 years of employment.

For more information and to apply, please visit us at For quick searching, enter Job ID 47607.

We are committed to equal employment opportunities to all persons without regard to race, color, religion, sex, age, national origin, sexual orientation, gender identity, disability or other such protected classes as may be defined by law.

Preferred Start Date: Open
Position Type:  Full Time

Date of Request: February 9, 2015
Job Title:  Lead Concurrent Documentation Specialist
Name of Facility/Hospital: Benefis Health System
Location of Facility/Hospital: Great Falls, MT
Contact Person/email/phone:  Amanda Stovall/
Contact Address: 1101 26th Street South, Great Falls, MT 59405

Job Description: The Lead Concurrent Documentation Specialist supports and provides oversight for programs including mentoring and providing leadership to concurrent review team on Program process, procedures and approach and monitors, evaluates and follow-up of program performance and use for modifying approach and or developing focus areas. The Documentation Specialist I addresses incomplete documentation with physicians to improve medical record physician documentation. The primary purpose is to improve medical record physician documentation by performing concurrent medical record reviews and addressing incomplete documentation with physicians by clinical documentation nurse reviewers.

FLSA:  Non-Exempt

Education/Experience Requirements:
Registered Nurse with a current license
Minimum of 5 years of acute care nursing is desired
Knowledge of CDI Program Process is desired

Email for any questions or apply at

Compensation: Based on years of relevant work experience
Benefits: Elgible for Medical, Dental, Vision, Flex/H.S.A, Life Insurance, Long Term Disability, and Pension Plan
Preferred Start Date: As soon as possible
Position Type:


Date of Request: February 9, 2015
Job Title: Clinical Documentation Integrity Specialist
Name of Facility / Hospital: University of Vermont Medical Center
Location of Facility / Hospital: Burlington, Vermont
Contact Person: Megan Brunovsky
Contact Address:

Job Description: The Clinical Documentation Integrity Specialist (CDIS) performs concurrent review of patient records to facilitate clarification of documentation by providers and clinicians. The intended outcome of documentation improvement is to ensure data quality for patient care and to completely and accurately reflect patient severity, risk of mortality, appropriate level of care and diagnosis terminology for appropriate reimbursement. Utilizes the American Hospital Association coding clinic guidelines and available reference tools to support educational opportunities during interactions with providers and clinicians to achieve documentation of accurate principal and secondary diagnosis within the patient record. The CDI should have exposure to the concepts of Interqual and/or Milliman criteria for inpatient admission. Proactively communicates with physicians, case management, and coding staff. Monitors and evaluates effectiveness of concurrent chart review and query outcomes and reports to the Supervisor of Clinical Documentation. Maintain accurate records of review activities to comply with departmental and regulatory agency guidelines. Understands and complies with policies and procedures related to confidentiality of medical records. Identifies opportunities for intradepartmental and interdepartmental operational improvement. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.

Compensation: Salary Range $64,792 - - $97, 198
Benefits: visit
Preferred Start Date: February 16, 2015
Position Type: Full-time , Permanent

Date of Request: February 6, 2015
Job Title: Clinical Documentation Specialist
Name of Facility / Hospital: Samaritan Health Services
Location of Facility / Hospital: Albany and Corvallis Oregon
Contact Person: Samaritan Health Serivces Recruiting
Contact Address:

Job Description: Provides analysis, information and education to assist physicians in using terminology that improves and supports documentation of patient care. Performs concurrent review and analysis of the clinical facts documented in the medical records. Concurrently queries the medical staff and other members of the healthcare team to obtain accurate and complete chart documentation that appropriately supports the severity of the patient's illness. Plans and provides education to the healthcare team regarding documentation requirements, clarity and completeness. Current Oregon Registered Nurse license required. BSN preferred. Five (5) years experience in an inpatient care setting required. Experience and/or training in Excel, Word and EMR required.
Experience in the following preferred:

  • Quality assurance chart review, coding, auditing and/or case management
  • Acute care utilization review or discharge planning
  • CU-CCU and/or ER 

Certified Clinical Documentation Specialist CCDS preferred.

Compensation: Salary Range: $32.91 - $48.33 per hour
Benefits: Samaritan Health Serivces offers an exceptional benefits package.
Preferred Start Date: March 6, 2015
Position Type: Full-time

Date of Request:  February 5, 2015 
Job Title:  Clinical Documentation Specialist
Name of Facility/Hospital: Maine Medical Center
Location of Facility/Hospital: Portland, ME
Contact Person/email/phone: (searching for Clinical Documentation Specialist)

Job Description: In this newly created role, reporting to a CDI Supervisor and the HIM Director, you will be responsible for improving the overall quality and completeness of all medical record documentation. You will work closely with physicians, nursing staff, and other patient caregivers and coordinate with the coding staff to ensure that appropriate reimbursement is received. This will include ensuring all clinical information is complete and accurate while educating members of the patient care team on documentation guidelines.

To qualify, you must be a dependable, self-directed RN with a current ME license (BSN or 4-year degree preferred) and possess recent clinical experience (minimum 5 years), preferably from an ED, ICU or med/surg environment. Highly developed problem solving, critical thinking and deductive reasoning abilities; demonstrated and effective organizational, prioritization and leadership skills, and excellent communication skills adaptable to individual levels of understanding are also essential.

Compensation: based on experience
Benefits: competitive salary and benefits, work life/balance
Preferred Start Date: February 15, 2015
Position Type: Full Time

Date of Request: February 4, 2015
Job Title: Manager of CDI/DRG Reimbursement
Name of Facility / Hospital: HIM Connections
Location of Facility / Hospital: Columbia, SC
Contact Person: Pat Lozito
Contact Address:

Job Description: Monitors case mix index and other indicators to develop educational curriculum and presentations for the physicians, clinicians, coders, and clinical documentation specialists. Assists with documentation improvement by monitoring reports and performance of documentation specialists to ensure success of the program. Utilizes documentation improvement system to track and trend results for optimal reimbursement. Assists with orientation and training of clinical documentation specialists and coders. Performs concurrent clinical documentation review in clinical areas, as necessary, in the event of backlogs, vacations, or vacancies. Maintains coding proficiency through continuing education, professional development, and/or coding.
Education: Bachelor's Degree in Health Information Management or related field preferred
Experience: Minimum 3+ years coding experience in an acute care setting.
Number of Employees Supervised: 4
Required: CCS, RHIA, or RHIT. CCDS a plus.
Special Training: Extensive knowledge of ICD-9CM and the DRG perspective payment system.

Compensation: Based on experience
Benefits: Based on employment type - permanent or interim.
Preferred Start Date: February 4, 2015
Position Type: Full-time, Permanent, Contract

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