Certified Epic Clinical Documentation Specialist (CDS)

​​​​Duration : 6+ months, Contract-to-Hire Location : Downtown Indianapolis, IN (On-site Tues / Thurs; Tues / Wed / Thurs during the first week of each month) Relocation Accepted : Yes

• U.S. Citizens and those authorized to work in the U.S. are encouraged to apply. We are unable to sponsor or transfer visas at this time.
• No Vendors / 3rd parties.
• The Certified Epic Clinical Documentation Specialist (CDS) is responsible for enhancing the accuracy, quality, and integrity of clinical documentation within the Epic Electronic Health Record (EHR) system. This role works closely with physicians, nurses, and other healthcare professionals to ensure documentation supports patient care, coding accuracy, quality reporting, and regulatory compliance. The ideal candidate is an experienced Clinical Documentation Specialist with Epic Certification in relevant modules (e.g., Epic CDI, Epic Inpatient, or Epic HIM). Responsibilities : Collaborate with providers and clinical staff to ensure documentation within Epic accurately reflects the severity of illness, complexity of care, and supports appropriate coding and reimbursement. Utilize Epic CDI tools to identify documentation improvement opportunities, issue queries, and track responses. Conduct concurrent and retrospective reviews of inpatient and outpatient medical records to ensure completeness and accuracy. Educate providers and staff on best practices for documentation and the effective use of Epic CDI features. Monitor and audit Epic documentation workflows to ensure compliance with clinical, coding, and regulatory standards (e.g., CMS, ICD-10, DRG, HCC). Generate and analyze reports and dashboards in Epic to track performance metrics, query response rates, and compliance trends. Participate in Clinical Documentation Improvement (CDI) team meetings and quality improvement initiatives. Stay current with clinical documentation guidelines, coding standards, and Epic system updates. Requirements : Registered Nurse (RN), Advanced Practice Provider (NP, PA), or relevant clinical background (e.g., RHIA, RHIT, CCS, MD). Epic Certification in applicable modules (e.g., Clinical Documentation Improvement, Inpatient Clinical Documentation, or Health Information Management). Minimum of 3 years of experience in clinical documentation improvement or health information management. Strong knowledge of ICD-10, MS-DRG, APR-DRG, and HCC coding systems. Familiarity with CMS guidelines, coding compliance, and audit processes. Excellent communication, critical thinking, and interpersonal skills. May require occasional travel between hospital campuses. Preferred Qualifications : Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP). Experience working in a hospital or academic medical center utilizing Epic EHR. Proficiency with Epic work queues, SmartForms, SmartTexts, and Reporting Workbench. 25-01025