Hiring: Clinical Documentation Specialist Company: Community Health Systems Location: Laredo, TX Job Posted Time: 2026-09-16 11:49:18 Employment Type: Hybrid Target Skills & Keywords : Clinical Documentation, Health Information Management, ICD-10, Regulatory Compliance About the job Experience: •3-5 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required •3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred •5 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required •5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred Required Skills: •This position is hybrid in Laredo, Texas at Laredo Medical Center. •Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity. •Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices. •Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries. •Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review. •Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts. •Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions. •Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation. Qualifications: •Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required •Bachelor's Degree in Nursing, Health Information Management, or a related field preferred •Operational familiarity with regulatory standards and quality metrics related to clinical documentation preferred •Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics. •Excellent analytical and problem-solving skills to identify opportunities for documentation improvement. •Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact). •Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams. •Demonstrated capacity to develop and deliver educational programs tailored to clinical and administrative audiences. •Strong organizational skills and attention to detail to manage multiple priorities and deadlines. •Commitment to maintaining compliance with regulatory standards and corporate policies. Interested candidates, please apply directly through the job posting on company's career page or try via AI auto apply on this platform. Don't miss this opportunity to join a forward-thinking team!