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Clinical Documentation Specialist, Clinical Documentation Improvement, Anywhere (Eligible States)
(251479) Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin. Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, and a network of clinics in the North Loop, Whittier, and East Lake Street neighborhoods of Minneapolis, and in the suburban communities of Brooklyn Park, Golden Valley, Richfield, and St. Anthony Village. Hennepin Healthcare has a large psychiatric program, home care, and operates a research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County. Equal Employment Opportunities: We believe equity is essential for optimal health outcomes and are committed to achieve optimal health for all by actively eliminating barriers due to racism, poverty, gender identity, and other determinants of health. We are committed to equitable care and working in an environment that celebrates, promotes, and protects diversity, equity, inclusion, and belonging. We are committed to bringing in individuals with new cultural perspectives to assist in creating a more equitable healthcare organization.
SUMMARY We are currently seeking a Clinical Documentation Specialist to join our Clinical Documentation Improvement team. This full-time role will primarily work remote (Day, M- F). Purpose of this position: Under the direction of Coding and Documentation leadership, provides active concurrent review, feedback, and education to physicians and healthcare providers to improve documentation of all conditions and treatments in the inpatient medical record, to ensure an accurate reflection of the patient condition in the associated MS-DRG assignments, case-mix index, severity of illness and risk of mortality profiling and reimbursement. Current List of non-MN States where Hennepin Healthcare is an Eligible Employer: Alabama, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Mississippi, Nevada, North Carolina, North Dakota, New Mexico South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin. RESPONSIBILITIES- Conducts initial and continued-stay concurrent reviews on inpatient admissions and documents findings using the designated CDI software, Coding software and Epic electronic record as necessary/ requires proficiency in abstracting the needed clinical information and data used for clinical documentation
- Identifies procedures and secondary diagnoses for co-morbidities/complications and documents appropriately within the designated CDI software, Coding software and Epic electronic record as needed to accurately calculate the correct DRG assignment
- Identifies documentation issues within the medical record around ICD-10-CM Diagnosis and ICD-10 PCS procedure codes
- Communicates via a query process to the Medical Staff, Advanced practice practitioners (APP’s) and other providers, including medical residents as necessary, via written/verbal communication to obtain accurate and complete provider documentation
- Assigns baseline and working DRG (APR or MS DRG), along with Severity of illness and Risk of Mortality to reviews using ICD-10-CM /PSC codes and procedures to all reviews
- Ensures the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record before patient discharge whenever possible
- Identifies potential Patient safety indictors (PSI) and Hospital acquired conditions (HAC) codes and notifies appropriate staff personnel for further review
- Conducts post discharge reviews and reconciliation of DRG assignment and baseline DRG, ensuring correct outcome for all coding queries responses
- Educates physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided. This may require the use of computer software and developing education using software such as PowerPoint
- Applies federal and state documentation and coding (ICD-10-CM/PCS) guidelines to ensure physician and hospital compliance. Maintains current knowledge of coding/documentation information including the AHA’s Coding Clinic publication, pharmacology, laboratory, disease processes, and new/emerging technologies to ensure accuracy of code assignment and compliance
- Identifies documentation trends and issues and reports these to CDI leadership, as well as the inpatient coding management and staff as needed
- Interacts with coding team to resolve documentation and coding issues and ensure proper DRG assignment
- Be able to prepare and provide service-specific information and education to physicians and other care providers, related to provider documentation and its effects on coding, compliance, profiling and reimbursement
- Participates in educational programs and in-services in order to maintain clinical documentation requirements, knowledge and ICD- 10-CM /PCS coding requirements
- Portrays a professional manner in dress and all communication skills
- Must have effective interpersonal skills to effectively interact, communicate, and maintain good working relationships with Medical Staff, Advanced Practice Practitioners (APP’s), other provers and team members
- Must be able to work with minimal supervision and assist others in completing the work of the team
- Performs other tasks as assigned
- Graduation from an accredited school of nursing, and two (2) years of professional nursing experience in an emergency department, medical or surgical area of an acute hospital setting,
- Graduation from an AHIMA accredited program as a Registered Health Information Administrator (RHIA) and at least three (3) years of recent inpatient coding experience,
- Graduation from an AHIMA accredited program as a Registered Health Information Technician (RHIT) and at least four (4) years of recent inpatient coding experience
- An approved equivalent combination of education and experience
- Experience in CDI activities
License/Certifications:
- Maintain current licensure by the Minnesota Board of Nursing as a Registered Nurse(RN)-OR-
- Registration as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) by the American Health Information Management Association.
Total Rewards Package:
- We offer a competitive pay rate based on your skills, licensure/certifications, education, experience related to this position, and internal equity.
- We provide an extensive benefits program that includes Medical; Dental; Vision; Life, Short and Long-term Term Disability Insurance; Retirement Funds; Paid Time Off; Tuition reimbursement; and license and Certification reimbursement (Available ONLY for benefit eligible positions).
- For a complete list of our benefits, please visit our career site on why you should work for us.
Department: Clinical Documentation Improvement
Primary Location
: MN-Minneapolis-Downtown Campus
Standard Hours/FTE Status: FTE = 1.00 (80 hours per pay period)
Shift Detail: Day
Job Level
: Staff
Employee Status
: Regular
Eligible for Benefits: Yes
Union/Non Union: Non-Union
Min: $39.20
Max: $58.80
Job Posting
: Oct-14-2025
