Clinical Documentation Specialist Clarity PartnersClinical Documentation SpecialistChicago, IL$50,000–$65,000 / yearExperience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation, obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided. You will facilitate necessary documentation through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of severity of illness/risk of mortality (SOI/ROM) for the level of service rendered to all patients.
Clinical Documentation Specialist - First Reviewer (H) SSM HealthClinical Documentation Specialist - First Reviewer (H)MissouriPerforms concurrent analytical reviews of clinical and coding data to improving physician documentation for all conditions and treatments from point of entry to discharge, ensuring an accurate reflection of the patient condition in the associated Diagnosis Related Group (DRG) assignments, case-mix index, severity of illness (SOI), and risk of mortality (ROM) profiling, and reimbursement. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.
Clinical Documentation Specialist Integrated Resources, IncClinical Documentation SpecialistLexington, MassachusettsContractorClinical Documentation Specialist is responsible for QC Review of pre-study and study documents, coding of administrative and regulatory documents, verification of documentation, maintenance of document tracking system, collaborating with CTM to determine to issues in regulatory documentation, and creates study specific document checklists in collaboration with the CTM and medical research. If yes, please explain and provide details: Note: Do not include convictions that have been annulled, erased, expunged, vacated, set aside, sealed by a court, or referred to a diversion program.
Senior Clinical Documentation Specialist AscensionSenior Clinical Documentation SpecialistRemoteRemote$87,463.20–$121,918.37 / yearFull timeHow you'll make an impact in this role: The Senior Clinical Documentation Specialist (CDS) - Float Pool is a versatile and experienced Clinical Documentation Integrity professional responsible for providing cross-coverage and high-level CDI support across Ascension’s multi-market system. 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.
NewClinical Documentation Specialist - Professional Ambulatory Texas Children's HospitalClinical Documentation Specialist - Professional AmbulatoryHouston, TXTexas Children's comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Tower for pediatric research; Texas Children's Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children's Hospital West Campus, a community hospital in suburban West Houston; Texas Children's Hospital The Woodlands, the first hospital devoted to children's care for communities north of Houston; and Texas Children's Hospital North Austin, the new state-of-the-art facility providing world-class pediatric and maternal care to Austin and Central Texas families. We have also created Texas Children's Health Plan, the nation's first HMO focused on children; Texas Children's Pediatrics, the largest pediatric primary care network in the country; Texas Children's Urgent Care clinics that specialize in after-hours care tailored specifically for children; and a global health program that is channeling care to children and women all over the world.
Clinical Documentation Specialist - Second Reviewer SSM HealthClinical Documentation Specialist - Second ReviewerMissouriPerforms as a vital member of the interdisciplinary care team member, an auditor, and an educator ensuring medical records are complete and clinical documentation comprehensively represents the current health status of network patients against ever-changing risk adjusted models. Applies the existing body of evidence-based practice and scientific knowledge in health care to nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's scope of service.
Clinical Documentation Specialist II Exempt AdventHealthClinical Documentation Specialist II ExemptRegistered 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 physicians, nurse practitioners, and other clinical team members.
Clinical Documentation Specialist II H. Lee Moffitt Cancer Center and Research Institute HospitalClinical Documentation Specialist IIThe Clinical Documentation Specialist II assesses clinical documentation through extensive medical record review and utilization of clinical judgment, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient.
Registered Nurse Clinical Documentation Specialist AscensionRegistered Nurse Clinical Documentation SpecialistShorewood, WisconsinRemote$79,511.52–$110,834.59 / yearFull timeCollaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge. What minimum qualifications you'll need: Licensure / Certification / Registration: One or more of the following required: Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
Clinical Documentation Specialist - Coding Pyramid Consulting, IncClinical Documentation Specialist - CodingOakland, CARemote$45–$50 / hourKey Requirements and Technology Experience: Minimum of four (4) years of clinical nursing experience in inpatient care, clinical documentation, discharge planning, or case management. Collaborate with physicians and medical coding staff to identify and clarify additional diagnoses impacting severity of illness and risk of mortality indicators.
RN Clinical Documentation Specialist - ST Peters Hospital Trinity Health CorporationRN Clinical Documentation Specialist - ST Peters HospitalAlbany, NY$31.50–$47.97 / hourMust possess one of the below: Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) required, licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients.
CLINICAL DOCUMENTATION SPECIALIST Sr H. Lee Moffitt Cancer Center and Research Institute HospitalCLINICAL DOCUMENTATION SPECIALIST SrThe Clinical Documentation Specialist Senior assesses clinical documentation through extensive medical record review and utilization of clinical judgment, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. Additionally, the Clinical Documentation Specialist Senior will collaborate with the Health Information Management (HIM) coding staff and the Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting outcomes is complete and accurate.
NewRegistered Nurse (Rn) - Clinical Documentation Specialist (Remote) University of VirginiaRegistered Nurse (Rn) - Clinical Documentation Specialist (Remote)Charlottesville, VARemote$67,859–$135,718 / yearDesigned for nurses ready to transition from direct patient care into a more analytical and collaborative role, this position offers the opportunity to leverage your clinical knowledge to improve documentation quality, support interdisciplinary teams, and drive positive patient outcomes. You will be most successful in this role if you bring: Strong acute care hospital experience, particularly in adult inpatient settings, along with experience working as a Clinical Documentation Specialist.
NewClinical Documentation Specialist Sanford HealthClinical Documentation SpecialistBismarck, ND$32.50–$44 / hourThe 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 Improvement Specialist - Full Time Lake Charles Memorial Health SystemClinical Documentation Improvement Specialist - Full TimeLake Charles, LAMust have one of the certifications/licensures: Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Physician Assistant (PA), Registered Nurse/BSN, RHIA, RHIT, or related clinical allied health degree. Clinical Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), or equivalent is a plus.
NewClinical Documentation Specialist II K3 InnovationsClinical Documentation Specialist IIVO, ILCreates and presents reports to study teams, collaborating with functional areas to finalize and archive study Master Files in the electronic Master File system, and supporting audit and inspection preparations to ensure Master File readiness. Provide training and support to new team members, serving as a mentor to guide best practices in document management and conducts QC Checks on document processing of internal and external staff to ensure quality thresholds are being met.
Clinical Documentation Specialist RN Hackensack Meridian HealthClinical Documentation Specialist RNHackensack, New JerseyFull timeObtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, Health Information Management Department coding staff, and Emergency Trauma Department (ETD), to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Responsibilities: A day in the life of a Clinical Documentation Specialist RN at Hackensack Meridian Health includes: Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
RN Clinical Documentation Specialist Endeavor HealthRN Clinical Documentation SpecialistSkokie, Illinois$38.67–$59.94 / hourOur more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals – Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) – all recognized as Magnet hospitals for nursing excellence. Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties.
QA/QC Clinical Documentation Specialist Winners Circle GroupQA/QC Clinical Documentation SpecialistDallas, TexasBachelor's degree in behavioral health, social work, healthcare administration, or related field (clinical licensure a plus but not always required). Conduct routine audits of clinical documentation (assessments, treatment plans, progress notes, dischargesummaries) for accuracy, timeliness, and compliance with state, federal, and payer regulations.
Clinical Documentation Specialist Audit and Education AscensionClinical Documentation Specialist Audit and EducationWaco, Texas$96,208.99–$134,109.89 / yearFull timeWhat additional requirements you'll need: Must have a Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS). Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system.