Clinical Documentation Improvement Specialist

    • Gambrills, MD


AbleVets, A Cerner Company, provides healthcare information technology services and resources to help the VA and DoD improve the lives of the people they serve. AbleVets has an opportunity for a motivated Clinical Documentation Improvement Specialist to add to our fast-growing organization. This position will be located on of our customer sites in Maryland, Washington DC, Virginia or West Virginia.


The Clinical Documentation Improvement Specialist shall conduct a comprehensive analysis of clinical documentation practices at the various VAMHCS clinical services to identify and understand potential deficiencies.  At a minimum, the analysis will include interviews with VA staff (such as providers and clerks), analyzing coding data, and performing documentation reviews. The report shall also include actionable recommendations for improvement.


The Clinical Documentation Improvement Specialist shall utilize industry standards to support the execution of an efficient Clinical Documentation Improvement Program.  This role shall provide a weekly status report of the support provided and status of each improvement effort underway.  Job duties will include but not be limited to:

  • Analyzes documentation of the clinical status of patients, current treatment plan, and past medical history
  • Identifies potential gaps in provider documentation.
  • Educates physicians and healthcare providers regarding clinical documentation improvements and need for accuracy in health record documentation
  • Collaborates with physicians, nursing staff, ancillary departments, and coding staff to ensure that clinical documentation is compliant, complete and accurate.
  • Collaborates with coding staff to ensure documentation is a complete reflection of the care received, as well as patient's clinical status, acuity, the severity of illness, and risk of mortality.
  • Serves as a resource to providers to help link coding guidelines and medical terminology, to improve the accuracy of the patient's severity of illness, the risk of mortality, final code assignment, and case mix index.
  • Implement government approved metrics to track the success of the Clinical Documentation Improvement program


  • Bachelor's degree in health information management, nursing or equivalent with five (5) years of relevant experience.  An additional six (6) years if the related experience can be substituted for degree requirement.
  • Currently licensed as a Registered Nurse or other relevant LIP (licensed independent practitioner)
  • Certified Clinical Documentation Specialist (CCDS) and/or Clinical Documentation Improvement Practitioner (CDIP)
  • Knowledge of VHA Handbook 1907.01, Health Information Management and Health Records, VHA Handbook 1907.03, HIM Clinical Coding Program Procedures, VHA Coding Guidelines, and Medical Staff Bylaws
  • Knowledge of coding and documentation concepts, guidelines and clinical terminology
  • Ability to interpret and analyze all information in a patient’s health record including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record
  • Clinical knowledge (anatomy and physiology, pathophysiology, and pharmacology)
  • Ability to establish and maintain strong verbal and written communication with providers
  • Knowledge of healthcare regulations that define healthcare documentation requirements, including, The Joint Commission, CMS, and VHA guidelines
  • Knowledge of coding rules and requirements to include: clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), MS-DRG structure, and POA indicators
  • Knowledge of severity of illness and risk of mortality indicators
  • Applied knowledge of documentation impact on reimbursement to include VERA funding through the Allocation Resource Center (ARC) and third-party payer requirements
  • Ability to obtain a Public Trust clearance
  • Travel up to 50% of the time locally
  • Work location - 50% of the time will be spent remotely or at separate location listed below:
    o Washington DC VA Medical Center (Washington, DC)
    o Beckley VA Medical Center (Beckley, WV)
    o Louis A. Johnson VA Medical Center (Clarksburg, WV)
    o Hershel “Woody” Williams VA Medical Center (Huntington, WV)
    o Martinsburg VA Medical Center (Martinsburg, WV)
    o Baltimore VA Medical Center (Baltimore, MD)
    o Perry Point VA Medical Center (Perryville, MD)

EEO Statement

AbleVets LLC appreciates your interest in our company as a place of employment.  We are proud to be an equal opportunity/affirmative action employer and are committed to hiring and retaining a diverse workforce.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, veteran status, or any other protected class.  AbleVets is a VEVRAA Federal Contractor. 

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