Clinical Documentation Specialist Centers HomeClinical Documentation SpecialistMargate, FloridaPosition Summary: Revival Home Health Care, a certified and respected home health agency, is seeking a dedicated Clinical Documentation Specialist (RN or LPN) to join our Clinical team. Key Responsibilities: Conduct detailed audits of clinical documentation for accuracy, completeness, and regulatory compliance.
RN Clinical Documentation Specialist Montefiore Nyack HospitalRN Clinical Documentation SpecialistIdentifies, investigates and evaluates practices and processes to facilitate continuous improvement in complete and accurate medical record documentation, including second level reviews as needed. 2. Develops process to identify opportunities for documentation improvement, intervenes with attending physicians and facilitates improvement in electronic medical record documentation (EPIC).
NewClinical Documentation Specialist Community First Medical CenterClinical Documentation SpecialistChicago, ILClinical Documentation Specialist will ensure the overall quality and completeness of clinical documentation in patient medical records through extensive concurrent review, and concurrent interaction with physicians, care team members, case management, health information management and others as applicable. Monitors the documentation process and facilitates modifications to documentation to ensure clinical severity and intensity of service is documented to support the level of service and treatment rendered, to ensure accurate description of reasons for admission, patient severity, risk of mortality and conditions present on admission.
Clinical Documentation Specialist Singing River Health SystemClinical Documentation SpecialistAlabamaRemoteThe Clinical Documentation Specialist improves the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that documentation reflects the complexity and severity of illness for a complete and accurate level of service rendered to patients. Work requires close visual and acuity and the ability to adjust the eye to bring an object into sharp focus, i.e. shift gaze from viewing a computer monitor to forms/printed material that are closer to compare data at close vision.
NewClinical Documentation Specialist I AdventHealthClinical Documentation Specialist IRegistered Nurse (RN) [Required] OR Physician Assistant (PA) [Required] OR Certified Registered Nurse Practitioner (CRNP) [Required] OR Advanced Practice Registered Nurse (APRN) [Required] OR Medical Doctor (MD) [Required] OR Doctor of Osteopathic Medicine (DO) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required]. Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.
RN Clinical Documentation Specialist Sanford HealthRN Clinical Documentation SpecialistFargo, North DakotaThe CDS utilizes the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes, provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct diagnosis related group (DRG). Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
Clinical Documentation Specialist CompassusClinical Documentation SpecialistSeattle, WARequired 1 year Demonstrated proficiency in Home Health OASIS Review including all types of OASIS Required 3 months Experience with an Electronic Medical Record (EMR) system EXPERIENCE Required/Preferred Minimum Experience Details Preferred OASIS Certification Preferred 1 year OASIS Review Experience and 1 Year Home Health Clinical Experience. Required upon hire: Washington Registered Nurse License (Vendor Managed) Or Required upon hire: California Registered Nurse License (Vendor Managed) Or Required upon hire: Oregon Registered Nurse License (Vendor Managed).
Registered Nurse/Clinical Documentation Specialist IMCS Group IncRegistered Nurse/Clinical Documentation SpecialistBeaverton, ORRemoteConsults with physicians, medical directors, or physician committees regarding requested health services, or appropriateness of services which have already been rendered, or on medical policy issues including interpretation or revision of existing documents. In addition, the position is responsible for providing medical treatment reviews, case management, and treatment interventions the promote cost effective medical care and early return to work in workers' compensation cases.
NewClinical Documentation Specialist RN (Remote) must live in TX, LA, WA, FL or GA Houston MethodistClinical Documentation Specialist RN (Remote) must live in TX, LA, WA, FL or GACinco Ranch, TexasRemoteHouston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care clinics, emergency care and imaging centers; and outpatient facilities. The health system consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the Texas Medical Center, seven community hospitals and one long-term acute care hospital throughout the Greater Houston metropolitan area.
Clinical Documentation Specialist - RN Residents of: TX, Louisiana , FL, GA, TN, WA only! Houston MethodistClinical Documentation Specialist - RN Residents of: TX, Louisiana , FL, GA, TN, WA only!Houston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care clinics, emergency care and imaging centers; and outpatient facilities. The health system consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the Texas Medical Center, seven community hospitals and one long-term acute care hospital throughout the Greater Houston metropolitan area.
Clinical Documentation Specialist Rochester Regional HealthClinical Documentation SpecialistEffective as of 03/02/2026, will consider active unrestricted RN candidates (or other clinicians as defined below) with at least 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU. For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.
Clinical Documentation Specialist (PRN) BryanLGH Medical CenterClinical Documentation Specialist (PRN)Lincoln, NEEDUCATION AND EXPERIENCE: Current Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required. GENERAL SUMMARY: Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation to support coding and reporting of high-quality healthcare data through independent clinical judgement and professional autonomy.
Clinical Documentation Specialist Midland HealthClinical Documentation SpecialistMidland, TexasFull timeRegistered Nurse – current license (ADN or BSN) with 5 years acute care experience or comparable degree in a healthcare-related discipline with 3-5 years recent coding experience and certification of one of the following preferred: Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS). • Concurrently queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
Sr. Clinical Documentation Specialist AscensionSr. Clinical Documentation SpecialistMurfreesboro, TennesseeRemoteFull timeHow you'll make an impact in this role: Lead & Mentor Across Markets: Serve as the resident Clinical Documentation Integrity (CDI) subject matter expert, guiding regional initiatives and mentoring colleagues across clinical and coding domains. Education: High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree with 1 year of experience OR 5 years of applicable cumulative job specific experience required.
Lead Clinical Documentation Specialist AscensionLead Clinical Documentation SpecialistRemoteRemote$96,208.99–$134,109.89 / yearFull timeHow you'll make an impact in this role: The Lead Clinical Document Specialist (CDS) – Rapid Response serves as a high-level clinical documentation integrity expert, deployed to address urgent, complex, or high-impact issues across the CDI program. The Rapid Response Lead works collaboratively across departments to drive accurate documentation, coding integrity, and risk adjustment capture, while supporting training, compliance, and data-driven decision-making.
Clinical Documentation Specialist Audit Coordinator (Remote) Trinity Health CorporationClinical Documentation Specialist Audit Coordinator (Remote)Livonia, MIRemote$41.43–$62.15 / hourDemonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record. Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients.
Clinical Documentation Specialist University of ArkansasClinical Documentation SpecialistLittle Rock, ArkansasApplies extensive clinical knowledge to read and analyze health record documentation, identifying all significant diagnoses, treatment, and procedures impacting acuity level and resources consumed throughout the current hospitalization; applies knowledge of disease processes, surgical procedures, UHDDS definitions, and the CMS/NCHS ICD-10 Official Coding Guidelines for Coding and Reporting to assign non-indexed terms to the appropriate class within the ICD-10 coding classification system. Registered Nurse (RN) with current license plus 4 years inpatient clinical experience in Emergency, Critical Care, or Medical/Surgical area with experience in Quality, Case Management, Clinical Audit, or Data Abstraction OR Coding professional with CCS certification and 6 years of inpatient coding experience with documented education in anatomy/physiology and pharmacology.
Outpatient Clinical Documentation Specialist DCH Health SystemOutpatient Clinical Documentation SpecialistTuscaloosa, AlabamaOverview: The Outpatient Clinical Documentation Specialist is responsible for activities which assist the hospital with processes for complete and accurate capture of documentation and charges for the facility outpatient services rendered. Performs review of accounts identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges.
Clinical Documentation Specialist Quincy Physician Administrative ServicesClinical Documentation SpecialistQuincy, MaineWorking collaboratively with providers, clinical leaders, coding professionals, and operational teams, you will identify opportunities for documentation improvement, provide individualized education, and help implement best practices that enhance the accuracy and completeness of the medical record. As a Clinical Documentation Specialist at Quincy Medical Group, you will play a key role in advancing our Value-Based Care initiatives by partnering with providers to improve clinical documentation, diagnosis capture, and coding accuracy.
RN Clinical Documentation Specialist Lead- Remote- Days Ochsner Clinic FoundationRN Clinical Documentation Specialist Lead- Remote- DaysNew Orleans, LouisianaRemoteIndividuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, and Washington D.C. If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or careers@ochsner.org.