Clinical Documentation Specialist

Job Summary and Responsibilities

As our Clinical Documentation Specialist, you will provide critical expertise in medical record accuracy and integrity, profoundly impacting patient care quality and financial compliance.Every day you will expertly review clinical documentation, query physicians for clarity and specificity, educate providers on documentation best practices, and meticulously ensure all records accurately reflect the patient's severity of illness and complexity of care.To be successful in this role, you will demonstrate outstanding analytical skills, strong knowledge of clinical coding guidelines, and a collaborative, detail-oriented demeanor, contributing to precise data, appropriate reimbursement, and improved patient outcomes.

• Provides expert level review of inpatient clinical records within 24-48 hours of appearing on CAC worklist with marker(s). Identifies gaps in clinical documentation that need clarification for accurate code assignment by ensuring that documentation accurately reflects the severity of illness, risk of mortality of the patient condition and acuity of care provided. Conducts follow-up reviews to ensure issues discussed and clarified by physician have been recorded in patient's chart.
• Communicates with physicians face to face and via clinical documentation query forms to clarify information, obtain needed documentation and educate for appropriate severity of illness. Conducts daily follow up communication with providers regarding existing queries to obtain needed documentation specificity. Engages and consults with VPMA/CMO/Physician Advisor or designee for CDI when needed to resolve provider issues such as answering CDI Query in a timely manner and participation in the clinical documentation.
• Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on DRG, and is able to impart this knowledge to physicians and other health team members. Identifies the most appropriate principal diagnosis, MCCs and CCs to accurately reflect the severity of illness and assign a Working DRG.
• Utilizes the Coding and Compliance approved query forms whether paper or electronic. Maintains accurate data in the tracking database.
• Provide timely feedback to providers regarding clinical documentation opportunities for improvement and successes.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends.

Job Requirements

Required

• At least 3 years of acute care experience
• Experience communicating and working closely with physicians
• Active Registered Nurse license in the State of California

Preferred

• Bachelors Degree
• Previous or current Case Management experience and/ or critical care experience
• 1-3 years of experience in Clinical Documentation Improvement
• One of the following certificates
  • Certified Cardiac Device Specialist (CCDS)
  • Clinical Documentation Improvement Professional (CDIP)
  • Certified Coding Specialist (CCS)

Where You’ll Work

Founded in 1989, Dignity Health at Mercy Hospital of Folsom is a 106-bed, acute care, nonprofit hospital located in Folsom, California. Serving over 60,000 patients annually, the hospital offers a full complement of services including heart care, cancer care, women’s health, and neurology. Additionally, Mercy Hospital of Folsom has been recognized as an LGBTQ+ Healthcare Equality Leader by the Human Rights Campaign Foundation. It is a Joint Commission-certified Primary Stroke Center, and has been awarded the AMA/ASA’s Get the Guidelines - Stroke Gold Plus Quality Achievement, recognizing the hospital’s commitment to providing the best stroke care. It was recently named a Leapfrog 2025 Top General Hospital.

One Community. One Mission. One California