Job Description

Location: St. Joseph Medical Center
Posted Date: 8/19/2022

The Clinical Documentation Specialist is responsible for improving overall quality and completeness of clinical documentation in the health record ensuring compliance with the organization’s coding procedures and standards. The Clinical Documentation Specialist facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through interaction with physicians, care management, nursing staff, other patient caregivers and medical record coding staff while striving to eliminate gaps and assisting providers with accurate and compliant documentation resulting in appropriate healthcare reimbursement and clinical outcomes. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals. Utilizes monitoring tools/software to track the progress of the CDI program. Maintains 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 improvements. Participates in program related meetings, physician and staff education, staff development, departmental activities and in-service opportunities.


Strong broad-based clinical knowledge and understanding of pathophysiology of disease processes. Excellent written and verbal communication skills, critical thinking skills and interpersonal skills to build effective partnering relationships with physicians, care management team, nursing staff, coding staff and other hospital staff. Able to present ideas and concepts effectively to physicians, management and employees. Ability to work independently in a time oriented environment. Ability to analyze problems and issues from a variety of perspectives and understand the legal, reimbursement and impact.


  • Five years of experience in an acute care setting.
  • Knowledge of care delivery documentation systems and related medical record documents.
  • Prior experience in clinical documentation improvement programs preferred.


  • RN License, required
  • RNs with case management experience preferred
  • RNs with utilization review experience preferred
  • CDIP or CCDS required after 2 years of continuous employment


  • Bachelor of Science degree in nursing, preferred.


  • Excellent communication skills both verbal and written
  • Good interpersonal skills
  • Able to establish good customer relationships with trust and respect
  • Computer skills: navigation and edit resolution through various Web based systems; Proficient use of Microsoft office, specifically excel, Word, Outlook
  • Self directed, motivated and a positive attitude
  • Must exhibit excellent organizational skills
  • Clinical documentation knowledge as it relates to DRGs, POA, MCCs and CCs preferred
  • Understanding of the coding classification systems, ICD-10, CPT, HCPCS
  • Clinical knowledge to read and analyze a patient’s health record
  • Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes

Additional Information


  • Medical, Dental & Vision
  • Employee Paid Life Insurance
  • 401K w/match after 1 year of service
  • Tuition Reimbursement
  • Up to 20% Employee Cafeteria and Café Discount
  • Discounted Tuition with affiliated University
  • Inexpensive Parking
  • Easy accessibility from Houston Freeways
  • Short and Long-Term Disability
  • Ancillary Insurance

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

Application Instructions

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