Clinical Documentation Specialist (CDI)

Presbyterian is seeking for a Clinical Documentation Specialist. This position requires a proactive individual with the confidence to address documentation concerns while maintaining positive relationships with medical staff. If you're ready to make a meaningful impact in clinical documentation, we'd love to hear from you!

We are seeking a detail-oriented Clinical Documentation Specialist to assist medical staff providers with accurate documentation in the medical record. This role involves daily review of physician documentation, tracking patient diagnoses and procedures, and ensuring that the level of service provided is accurately reflected.

Tpe of Opportunity: Full Time (1.0) - Exempt: Yes

Job is based at Presbyterian Hospital

Work hours: Weekday Schedule Monday-Friday

How you grow, learn and thrive matters here.

Educational and career development options, including tuition and certification reimbursement, scholarship opportunities
• Staff Safety (A wearable badge that allows employees to quickly and discreetly call for help when safety is a concern)
• Shift differentials for nights and weekends
• Differentials for higher education, certifications and various lead roles
• Malpractice liability insurance
• Loan forgiveness through the New Mexico Higher Education Department
• EPIC electronic charting system

• Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required
• Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS).
• Working knowledge of medical terminology, ICD-10, CPT, HCPCS, DRG, disease processes and related procedures required.
• Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.
• Experience with database, spreadsheet and word process required.
• Detail and results oriented, with the ability to maintain accurate, detailed and organized records essential.
• Education specialization: Nursing

• Review physician documentation daily for accuracy and completeness.

• Track patient diagnoses and procedures to ensure appropriate service levels are documented.

• Work closely with physicians and staff to verify that clinical information is accurately captured.

• Address clinical documentation issues with confidence, ensuring compliance with regulatory requirements.

• Communicate effectively with medical staff, resolving any concerns about documentation needs.

• Maintain professionalism and tact while obtaining medical staff cooperation.Strong understanding of clinical documentation and regulatory guidelines.

• Excellent communication and collaboration skills.

• Ability to work independently and prioritize tasks effectively.

• Experience handling documentation challenges and ensuring compliance.

• Team player with a flexible approach to workload management.

We're all about well-being, starting with yours.
Presbyterian employees have access to a fun, engaging and unique wellness program, including free on-site and community-based gyms, nutrition coaching and classes, mindfulness and meditation resources, wellness challenges and more.

Learn more about our employee benefits.

About Presbyterian Healthcare Services

Presbyterian exists to improve the health of patients, members and the communities we serve. As a mission-driven organization, Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers' markets and local partnerships. Founded in 1908, Presbyterian is a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. With nearly 14,000 employees, it is the largest private employer in the state, serving over 580,000 health plan members through Medicare Advantage, Medicaid, and Commercial plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.