University of Mississippi Medical Center
Location
Clinton, Mississippi
The Clinical Documentation Specialist II reviews inpatient medical records to ensure accuracy and completeness, identifying documentation opportunities that reflect severity of illness and resource consumption. They communicate with healthcare providers regarding documentation improvements and assist in developing educational materials.
Candidates must have five years of clinical nursing experience in acute care or related fields, with a valid RN license required. A CCDS certification is preferred upon hire but must be obtained within three years.
Reviews inpatient medical record within 24-48 hours of admission to ensure accuracy and completeness and identifies documentation opportunities that reflect severity of illness, acuity, and resource consumption. Assigns a working DRG based on principal diagnosis and procedure. Identifies comorbidities and complications. Identifies Present on admission diagnoses. Identifies quality issues and reports to the responsible party. Is proficient in more complex decision-making with high degree of accuracy. Reviews and enters information in both epic and 3m 360 as required. Proficient in using these software systems. Ensures accuracy by reviewing inpatient charts every 24-48 hours as a follow-up. Identifies documentation that reflects the severity, acuity, quality issues and resource consumption and updates his/her findings in 3m 360 software. Proficient in quality and production. Communicates with physicians and other patient care providers, both verbally and written in a clear and concise way, regarding documentation opportunities for improvement. Assists in development and presentation of educational materials regarding documentation to both cdi staff and/or providers and other members of the healthcare team. Proficient effective assessment skills to identify clinical indicators for diagnoses. Integrates new or current techniques (of procedures or surgery, cdi issues, opportunities for documentation improvement) to obtain information as it relates to the planning, implementing, and evaluating of patient care documentation. Provides timely internal/external customer service in a cooperative, professional, and respectful manner. Ability to formulate a more complex query in order to obtain clarifications of conflicting, ambiguous, or non-specific documentation, by verbal or written compliant queries. Ability to determine when it is appropriate to escalate an issue to senior team member, provider, or administrator. Collaborates with CDI Specialist III to review individual problematic cases and/or educational needs. Has a highly developed understanding of what constitutes a risk management and/or quality program (PSI/HAC) case, and discusses with senior team member, as appropriate. Must maintain a current ACDIS Certification status. Participates in CDI-related education activities to maintain certifications and licensures. Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics. Contributes to a positive work environment and performs other duties as assigned or directed to enhance the overall efforts of the organization. Maintains UMMC network security of personal health information of the medical record. Employee must set aside a dedicated workspace at home. Employee must ensure that confidential material cannot be accessed or viewed by unauthorized person during their working hours. All information containing any phi (personal health information) must be shredded. Performs any other assigned duties since the duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time. Environmental and Physical Demands: Requires no exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, no handling or working with potentially dangerous equipment, occasional working hours beyond regularly scheduled hours, occasional travelling to offsite locations, frequent activities subject to significant volume changes of a seasonal/clinical nature, constant work produced is subject to precise measures of quantity and quality, occasional bending, occasional lifting/carrying up to 10 pounds, occasional lifting/carrying up to 25 pounds, no lifting/carrying up to 50 pounds, no lifting/carrying up to 75 pounds, no lifting/carrying up to100 pounds, no lifting/carrying 100 pounds or more, occasional climbing, no crawling, occasional crouching/stooping, occasional driving, no kneeling,occasional pushing/pulling, frequent reaching, frequent sitting,frequent standing,occasional twisting, and frequent walking. (Occasional-up to 20%, frequent-from 21% to 50%, constant-51% or more) Time Type: FLSA Designation/Job Exempt: No Pay Class: Hourly FTE %: 100 Work Shift: Benefits Eligibility: Grant Funded: Job Posting Date: 05/29/2026 Job Closing Date (open until filled if no date specified): The University of Mississippi Medical Center is committed to educating the next generation of health professionals, discovering new cures and treatments and providing the highest quality health care. We foster environments that support respect, compassion and belonging for all faculty, staff and students as well as patients and visitors. Our employment, academic, research and clinical care practices reflect these commitments. UMMC is an equal opportunity employer and prohibits discrimination and harassment on the basis of race, color, national origin (including limited English proficiency and primary language), disability, age, sex (as that term is defined in applicable laws such as 45 CFR § 92.101(a)(2) and binding court decisions), religion, genetic information, veteran’s status and any other status protected by applicable law. UMMC also prohibits retaliation against those who report discrimination or harassment and against those who participate in the Medical Center’s investigation and handling of such reports. Further, UMMC complies with all applicable statutes, regulations and executive orders regarding sex discrimination, sexual harassment, domestic and dating violence, sexual assault and stalking, including but not limited to Title IX of the Education Amendments of 1972 and its implementing regulations which prohibit discrimination on the basis of sex in any education program or activity UMMC operates including in admission and employment, the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistic Act (“Clery Act”) and the Campus Sexual Violence Elimination Act (“SaVE Act”). UMMC’s commitment to nondiscrimination applies to all of its programs, services, opportunities and activities, including but not limited to all employment, academic, research and clinical care practices and extends to all students, applicants for admission, employees, applicants for employment, affiliates, subcontractors, on-site contractual staff, third party or community members, visitors to any of our campuses and others participating in UMMC programs or receiving UMMC services. With respect to employment in particular, this commitment applies to all employment decisions including but not limited to recruitment, employment, training, promotion, compensation, benefits, disciplinary actions and termination. UMMC maintains an affirmative action program in accordance with applicable laws. Consistent with these laws, UMMC takes affirmative action to recruit, employ, advance and prevent discrimination against qualified individuals. For additional information, please check here: Know Your Rights: Workplace discrimination is illegal (eeoc.gov). In compliance with Section 1557 of the Patient Protection and Affordable Care Act and other federal civil rights laws and to ensure individuals with disabilities and those with limited English proficiency have meaningful access to, have an equal opportunity to participate in and have an equal opportunity to enjoy the benefits of our programs, activities, services and other benefits, UMMC provides the following in a timely manner and free of charge: reasonable modifications to our policies, practices, or procedures for qualified individuals with disabilities when such modifications are necessary to avoid discrimination on the basis of disability; appropriate auxiliary aids and services for individuals with disabilities (including individuals’ companions with disabilities) which may include qualified sign language interpreters and written information in other formats including braille and large print and language assistance services for individuals with limited English proficiency (including individuals’ companions with limited English proficiency) which may include qualified interpreters and information written in other languages. Complaint Process You may request additional information, accommodation or file a complaint through the applicable process identified below. Inquires or complaints relating to discrimination or other employment issues may be referred to the Office of Employee Relations, 2500 North State Street, Jackson, Mississippi 39216-4505 or emailed to hremployeerelations@umc.edu. If you are a UMMC Student who needs more information or needs to file a complaint, please click here. You may also report any allegations of UMMC’s noncompliance with any legal requirement using UMMC’s Compliance Line. If you are anyone who has experienced, witnessed or otherwise has knowledge of any alleged violation of UMMC’s Title IX policy, please click here. If you are a Visitor/Patient who needs more information or needs to file a complaint, please click here. Finding the perfect job can take time and we want to make your search easier. 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