Clinical Documentation Specialist

Tenet Healthcare

. Initiate and perform concurrent documentation reviews of selected inpatient records to clarify conditions, diagnoses, and procedures where inadequate or conflicting documentation is suspected .

Posted 10/2/2026full-timePhoenix • Arizona • United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation improvement, including ICD-10-CM coding guidelines and MSDRG assignment, while effectively communicating with healthcare professionals to enhance documentation accuracy and compliance. Possesses strong critical thinking and interpersonal skills to foster collaboration and education among clinical staff.

Highest-signal resume keywords

ICD-10-CM Coding GuidelinesClinical Documentation Improvement (CDI)MSDRG AssignmentRN, RHIA, RHIT, CCS, CIC, MD, DO, PA, NP CertificationCommunication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Documentation ReviewQuery ReconciliationDRG ReconciliationCoding ComplianceMedical TerminologyPerformance ImprovementChart ReviewEducational Program DevelopmentCritical ThinkingCare Delivery Documentation Systems

Soft Skills

Interpersonal SkillsSelf-MotivationPositive AttitudeTime ManagementTeam Collaboration

Tools & Technologies

Office EquipmentDocumentation Systems

Certifications & Qualifications

RNRHIARHITCCSCICMDDOPANP

Industry Keywords

Inpatient CodingAcute Care ExperienceOIG Work PlanPhysician DocumentationCompliance Standards

About the role

Key responsibilities & impact

Initiate and perform concurrent documentation reviews of selected inpatient records to clarify conditions, diagnoses, and procedures where inadequate or conflicting documentation is suspected
Meet or exceed defined performance standards for chart reviews and queries
Educate physicians, clinicians, and other involved parties on complete and clear documentation of patient care, including complications and comorbidities
Use queries, face-to-face communications, and educational programs and tools to improve documentation
Serve as a resource linking ICD-10-CM coding guidelines and medical terminology to accurate final code assignment
Follow coding and documentation guidelines to ensure physician and hospital compliance
Maintain current coding knowledge and participate in educational programs and in-services
Perform CDI Final Review/DRG Reconciliation and report DRG mismatch disagreements for secondary review
Perform query reconciliation and monitor query outcomes for performance opportunities
Support the Coding Department by communicating with physicians regarding open queries and acting as liaison between coding and physicians
Participate in special projects involving physician documentation accuracy
Precept and mentor new team members
Collaborate with the Physician Advisor to identify physician documentation issues, query utilization, and education opportunities
Maintain hospital and departmental policies, performance improvement, safety, environmental, infection control, confidentiality, and security standards
Perform other related tasks and responsibilities as assigned

Requirements

What you’ll need

Knowledge of care delivery documentation systems and related medical record documents
Detailed knowledge and understanding of MSDRGs and OIG work plan as it relates to correct coding and MSDRG assignment
Excellent written and verbal communication skills
Critical thinking skills and interpersonal skills to build effective relationships with physician, case management, nursing, coding, and hospital staff
Computer skills and familiarity with basic office equipment required
Ability to work independently in a time oriented environment
Self-directed, motivated, and possess a positive attitude
Graduate of an accredited school of nursing, AHIMA accredited school, or United States or international school of medicine
0–2 years of CDS experience and 2 years recent acute care experience in a clinical or inpatient coding setting
One of the following is required: RN, RHIA, RHIT, CCS, CIC, MD, DO, PA, or NP

Benefits

Comp & perks

Medical, dental, vision, and life insurance
401(k) retirement savings plan with employer match
Generous paid time off
Career development and continuing education opportunities
Health savings accounts
Healthcare and dependent flexible spending accounts
Employee Assistance program
Employee discount program
Voluntary pet insurance
Voluntary legal insurance
Voluntary accident and critical illness insurance
Voluntary long term care insurance
Elder and childcare benefits
Auto and home insurance