Stillwater Medical Center


Our team is growing! Come join the HIS Team at SMC!

SMC has a NEW position for an Outpatient Clinical Documentation Specialist (OP-CDS). Candidate should be a RHIA/RHIT with CCS/CDIP OR Registered Nurse with CCS/CDIP. Will consider candidates who are eligible for certification as well. Onsite position with possible transition to remote as program develops. Sign on bonus offered depending on education and experience.

Find out why SMC was ranked one of the Top 100 Best Places to Work by Modern Healthcare magazine for 5 years in a row!

Job Description:

The OP-CDS is responsible for reviewing ambulatory medical records for proper documentation to accurately reflect the care provided to the patient. The OP-CDS will prospectively review patient records for the clinic to ensure appropriate capture of all comorbid conditions being monitored, evaluated, assessed and treated. The OP-CDS logs CDI cases, queries, opportunities for improvement and practitioner response rates in tracking system; monitors trends; and provides feedback to physicians concurrently to support the overall objectives of the Clinical Documentation Integrity program.

Required Qualifications:

Associate’s degree in Health Information Management or Nursing required.
RHIT/RHIA, RN or LPN with 5-years hospital experience required.
One-year experience with ICD-10-CM and PCS required.
One-year experience with encoders and abstracting required.
Experience with following the AHIMA/ ACDIS Query process
Strong organizational, written, communication and presentations skills

Preferred Qualifications:

Advanced certification with CCS-P, CDIP or CCDS preferred
3-5 years Professional Billing and coding experience preferred
3-5 years Hospital billing and outpatient billing experience preferred
1-2 years minimum in Clinical Documentation Integrity/Improvement preferred

Education Qualifications:

Minimum Associates Degree in HIM or Nursing


Full time remote position with benefits!

Quarterly Incentive and Sign-On Bonus Offered!

Instructions for Resume Submission:

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