3,293 Healthcare Documentation Specialist jobs in the United States

At BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that's built on a foundation of trust, dignity, respect, responsibility and clinical excellence.
BayCare is currently in search of our newest Team Member who is passionate about providing outstanding customer service to our community. We are looking for an individual seeking a career opportunity with one of the largest employers within the Tampa Bay area.
**Position Details:**
+ **Location:** Fully Remote (must reside in the State of Florida)
+ **Status:** Full-time (non-exempt)
+ **Shift:** 10:00 AM to 6:30 PM (may vary)
+ **Hours:** Monday - Friday and occasional weekends
The Healthcare Documentation Specialist will work remotely on a Full-time basis. This team member must currently reside in FL.
**Responsibilities:**
+ The Healthcare Documentation Specialist transcribes, edits, and interprets dictation by BayCare physicians and clinicians to provide timely release of medical information to the EMR.
+ Assists manager/director with mentoring/training of new team members.
+ Requires in-depth knowledge of all aspects of medical terminology, medications, anatomy and physiology necessary for accurate documentation.
+ Performs other duties as assigned.
**Minimum Qualifications:**
Certifications and Licensures
+ **Preferred:** CHDS (Certified Healthcare Documentation Specialist).
Education
+ Required High School or equivalent
+ **Preferred:** Associates in a related field
Experience
+ Required 1 year of Medical Transcription/Editing.
+ **Preferred:** Pathology experience
Why BayCare?
Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that is built on a foundation of trust, dignity, respect, responsibility, and clinical excellence. Our team members focus on tomorrow by achieving personal and professional success today. That is why you will thrive in our forward-thinking culture, where we combine the best technology with compassionate service. We blend high-tech with high touch in ways that are advancing superior health care throughout the communities we serve.
Equal Opportunity Employer Veterans/Disabled
**Position** Healthcare Documentation Specialist
**Location** US:Florida | Business and Administrative | Full Time
**Req ID**

Founded in 1938, Wilcox Medical Center is a not-for-profit medical center dedicated to providing the Kaua'i community with accessible quality health care. The largest medical center on Kaua'i, it is a state-of-the-art acute care facility with a full suite of services offering 30 specialties and programs, including cardiology, emergency, family practice, gastroenterology, health management, internal medicine, neurology, OB-GYN, oncology, orthopedics, pediatrics and urology. Its 18-bed emergency department serves as the island's Primary Stroke Center. The medical center also has four birthing suites, seven intensive care beds and 20 same-day surgery beds. Wilcox is the first American College of Surgeons-verified Level III Trauma Center in the state of Hawai'i. Wilcox is part of Hawai'i Pacific Health, one of the state's leading health care systems and a not-for-profit health care organization with medical centers, clinics, physicians and other caregivers working together to create a healthier Hawai'i.
Health Information Services (HIS) processes patient medical records and releases health information to patients, physicians, and other outside facilities for treatment, payment, or review. HIS is the custodian and gatekeeper for privacy of the organization's medical records and also generates the coding procedures for data collection, research, and reimbursement. With the widespread computerization of health records and other information sources, including hospital administration functions and health human resources information, health informatics and health information technology are being increasingly used in the health care sector.
If you are highly organized and detail-oriented, you can help to manage our clinical records according to the highest ethical standards of patient privacy and security. As the Clinical Documentation Specialist, you will work to improve the overall quality of medical record documentation to ensure compliance with Medicare and Medicaid (CMS) guidelines and to expedite reimbursement. You will use both clinical and coding knowledge to obtain documentation through extensive interaction with physicians, nursing, other patient caregivers, Case Management and Health Information Management staff. You will also ensure that the clinical information used in measuring and reporting outcomes is complete, accurate, and that reimbursement is received for services rendered to patients with DRG-based payers. You will also educate members of the patient care team on documentation guidelines. We are looking for someone with exceptional organizational and communication skills, attention to detail and protocol and a commitment to delivering the highest quality health care to Hawai'i's people.
**Location:** Wilcox Medical Center
**Work Schedule:** Day - 8 Hours
**Work Type:** Full Time Regular
**FTE:**
**Bargaining Unit:** Non-Bargaining
**Exempt:** Yes
**Req ID** 30343
**Pay Range:** 108,534.40 - 153,483.20 USD per hour
**Category:** Health Information Management
**Minimum qualifications:** Current Hawai'i Registered Nurse License. Bachelor's degree and/or equivalent combination of education, training and experience. Five (5) years of clinical experience in an acute care setting that include inpatient bedside nursing.
**Preferred Qualifications:** Clinical Documentation Improvement (CDI) certification. Experience with InterQual, Milliman or other nationally recognized Utilization Management criteria. Experience with DRGs or inpatient ICD-10-CM/PCS coding.
EOE/AA/Disabled/Vets
Hawai'i Pacific Health offers a comprehensive and competitive total rewards package that includes pay and benefits. Rate of pay for selected candidates will be determined by various factors including knowledge, skills, abilities, relevant experience and training, as well as internal peer equity.

**Details**
+ **Department:** Population Health Quality Department
+ **Schedule:** Full-time Hybrid - 1-2 days of onsite work required
+ **Hospital:** Ascension Alexian Brothers
+ **Location:** Elk Grove Village, IL
+ **Salary:** $79,059.75 - $110,204.85 per year
Must live in Illinois due to weekly travel requirement
**Benefits**
Paid time off (PTO)
Various health insurance options & wellness plans
Retirement benefits including employer match plans
Long-term & short-term disability
Employee assistance programs (EAP)
Parental leave & adoption assistance
Tuition reimbursement
Ways to give back to your community
_Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer._
**Responsibilities**
Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.
+ Complete admission reviews and assign a working Diagnosis Related Group.
+ Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
+ Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
+ Collaborate 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.
+ Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.
**Requirements**
Licensure / Certification / Registration:
+ One or more of the following required:- Certified Coding Specialist (CCS) credentialed from the American Health Information ManagementAssociation (AHIMA) obtained prior to hire date or job transfer date.- Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders(AAPC) obtained prior to hire date or job transfer date.- Clinical Documentation Prof. credentialed from the Association of Clinical Documentation ImprovementSpecialists obtained prior to hire date or job transfer date.- Registered Nurse credentialed from the Illinois Department of Financial and Professional Regulationobtained prior to hire date or job transfer date.- Reg Health Info Admnstr credentialed from the American Health Information Management Association(AHIMA) obtained prior to hire date or job transfer date.- Reg Health Info Tech credentialed from the American Health Information Management Association(AHIMA) obtained prior to hire date or job transfer date.
+ Preferred Credential(s):- Approved Local Exception
Education:
+ High School diploma equivalency with 2 years of cumulative experience OR Associate'sdegree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.
**Additional Preferences**
**Minimum Requirements:**
+ **Medical Assistants with ICD-10 coding experience strongly recommended to apply**
+ **Required Certifications/Licensure:** Candidates must have the following certification thru AAPC (credentialing board): **Certified Risk Adjustment Coder (CRC) - STRONGLY PREFERRED**
+ **Hybrid position** - Flexible with local IL traveling, required (Northwest and Chicago Metro facilities) - **must reside in Illinois due to travel requirement**
+ **Minimum Education:** High School Diploma or Equivalent
+ **Minimum Years of Experience:**
+ **Current Students in the CRC program please apply!**
+ 1 year **RISK CODING** experience, preferred (NEW GRADUATES WELCOME)
+ Experience in HCC or chronic condition coding
+ Experience in medical practice outpatient setting
**Why Join Our Team**
Ascension Illinois delivers compassionate, personalized care throughout Chicago and its surrounding suburbs. As one of the largest health systems in Illinois with 15 hospitals and more than 230 sites of care, you will find an environment that allows you to thrive and create a career path you love. Join a diverse team of more than 17,000 associates and more than 600 providers who are dedicated to providing compassionate, personalized care to all.
Ascension is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care, including more than 140 hospitals and 40 senior living communities in 19 states.
Our Mission, Vision and Values encompass everything we do at Ascension. Every associate is empowered to give back, volunteer and make a positive impact in their community. Ascension careers are more than jobs; they are opportunities to enhance your life and the lives of the people around you.
**Equal Employment Opportunity Employer**
Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws.
For further information, view the EEO Know Your Rights (English) ( poster or EEO Know Your Rights (Spanish) ( poster.
As a military friendly organization, Ascension promotes career flexibility and offers many benefits to help support the well-being of our military families, spouses, veterans and reservists. Our associates are empowered to apply their military experience and unique perspective to their civilian career with Ascension.
Pay Non-Discrimination Notice ( note that Ascension will make an offer of employment only to individuals who have applied for a position using our official application. Be on alert for possible fraudulent offers of employment. Ascension will not solicit money or banking information from applicants.
**E-Verify Statement**
This employer participates in the Electronic Employment Verification Program. Please click the E-Verify link below for more information.
E-Verify (

USD $35.59/Hr. to USD $3.73/Hr.Welcome to CommonSpirit Health Mountain Region:
CommonSpirit Health Mountain Region is committed to building healthier communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen-both inside our hospitals and out in the community. With locations throughout Colorado, Utah, and Kansas, we deliver the same high standard of care to our employees as we do to our patients. Our 20 hospitals, emergency and urgent care centers, home care and hospice, Flight for Life Colorado TM , telehealth and over 240 physician practices and clinics offer endless opportunities! Here, you can grow your career and impact the people in the communities you serve.
CommonSpirit Health is one of the nation's largest nonprofit, faith-based health systems, with a team of over 150,000 employees and 25,000 physicians and advanced practice clinicians. CommonSpirit operates more than 2,200 care sites and 140 hospitals, serving some of the most diverse communities across the nation, letting humankindness lead the way.
Overview:
As a Clinical Documentation Integrity (CDI) Specialist, you will work under indirect supervision, facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. In this role you will be you will:
+ Educate members of the patient care team regarding documentation guidelines and regulatory requirements, including attending physicians, allied health practitioners, nursing, and case management.
+ Support timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes
+ Work independently majority of the time with a high degree of autonomy.
Qualifications:
In addition to bringing humankindness to the workplace each day, qualified Clinical Documentation candidates will need the following:
Education Requirements
+ Nursing Diploma or Associates Degree Required
+ BSN preferred
License/Certification Requirements
+ Current RN license in state of employment or valid RN license from compact state, required
+ CCDS, preferred
+ CDIP, preferred
Experience Requirements
+ Three years of nursing experience in the inpatient hospital setting (critical care and/or strong med/surg experience preferred) or two years of nursing experience in the inpatient hospital setting and one year of CDI experience
+ Must demonstrate Clinical competency through successfully passing Clinical Competency exam through Nuance
+ Must demonstrate CDI software competency through passing Clintegrity exam within six months of starting role
+ Proficiency with MS Office software
+ Proficient in use of Electronic Health Record
+ Experience in health information management or hospital quality program preferred
+ Self-motivated with excellent interpersonal, critical thinking, analytical, organizational, and writing skills
Physical Requirements
+ Sedentary work -(prolonged periods of sitting and exert up to 10lbs force occasionally)
Your Connected Community:
At CommonSpirit Mountain Region, we believe in the healing power of humanity and serving the common good through our dedicated work and shared mission to celebrate humankindness.
Our Total Reward Offerings:
Be sure to consider our generous benefits as part of your overall compensation! Designed with your well-being in mind, our benefits include:
+ Medical
+ Dental
+ Vision
+ 401K with generous match
+ Daycare FSA that can include a company contribution
+ Tuition Reimbursement
+ Student Loan Forgiveness and more!
View more on our benefits HERE ( .
Pay Range:
35.59 - 53.73 / hour
Shift: Days
We are an equal opportunity employer.

**Job Summary**
The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.
**Essential Functions**
+ Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
+ Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices.
+ Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
+ Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
+ Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
+ Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
+ Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
+ Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
+ Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
+ Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
+ Performs other duties as assigned.
+ Maintains regular and reliable attendance.
+ Complies with all policies and standards.
**Qualifications**
+ Associate Degree in Nursing, Health Information Management, or a related field required
+ Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
+ 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required
+ 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred
+ Experience in physician education or query processes preferred
+ Familiarity with regulatory standards and quality metrics related to clinical documentation preferred
**Knowledge, Skills and Abilities**
+ Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
+ Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
+ Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact).
+ Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
+ Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
+ Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
+ Commitment to maintaining compliance with regulatory standards and corporate policies.
**Licenses and Certifications**
+ RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required
+ CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
+ Certified Clinical Documentation Specialist (CCDS) preferred
+ RHIT - Registered Health Information Technician preferred or
+ RHIA - Registered Health Information Administrator preferred
+ CDIP - Clinical Documentation Improvement Professional preferred or
+ Certified Coder-AHIMA or AAPC preferred
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to to obtain the main telephone number of the facility and ask for Human Resources.

**Job Summary**
The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.
**Essential Functions**
+ Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
+ Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices.
+ Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
+ Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
+ Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
+ Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
+ Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
+ Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
+ Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
+ Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
+ Performs other duties as assigned.
+ Complies with all policies and standards.
**Qualifications**
+ Associate Degree in Nursing, Health Information Management, or a related field required
+ Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
+ 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required
+ 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred
+ Experience in physician education or query processes preferred
+ Familiarity with regulatory standards and quality metrics related to clinical documentation preferred
**Knowledge, Skills and Abilities**
+ Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
+ Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
+ Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact).
+ Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
+ Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
+ Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
+ Commitment to maintaining compliance with regulatory standards and corporate policies.
**Licenses and Certifications**
+ RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required
+ CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
+ Certified Clinical Documentation Specialist (CCDS) preferred
+ RHIT - Registered Health Information Technician preferred or
+ RHIA - Registered Health Information Administrator preferred
+ CDIP - Clinical Documentation Improvement Professional preferred or
+ Certified Coder-AHIMA or AAPC preferred
INDNC
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to to obtain the main telephone number of the facility and ask for Human Resources.

**Details**
+ **Department:** Case Management
+ **Schedule:** Full-time, 1.0 Salaried
+ **Hospital:** Ascension Columbia St. Mary's Milwaukee, WI
+ **Location:** Remote
+ **Salary:** $75, , per year
**Benefits**
Paid time off (PTO)
Various health insurance options & wellness plans
Retirement benefits including employer match plans
Long-term & short-term disability
Employee assistance programs (EAP)
Parental leave & adoption assistance
Tuition reimbursement
Ways to give back to your community
_Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer._
**Responsibilities**
Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.
+ Complete admission reviews and assigns a working Diagnosis Related Group. Ensures the working DRG and other information are entered in the Clinical Documentation Improvement database.
+ Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
+ Collaborate 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.
+ Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.
**Requirements**
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.
+ Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
+ Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
+ Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
+ Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
+ Registered Nurse credentialed from the Wisconsin Board of Nursing obtained prior to hire date or job transfer date. Licensure from the Wisconsin Board of Nursing OR current home state license if considered multi-state/Compact State.
Education:
+ High School diploma equivalency with 2 years of cumulative experience OR Associate'sdegree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.
**Additional Preferences**
No additional preferences.
**Why Join Our Team**
Ascension Wisconsin has been providing rewarding careers to healthcare professionals since 1848. Operating 17 hospital campuses and over 100 related healthcare facilities from Racine to Appleton, you will find opportunities that allow you to create a career path you love, all while delivering compassionate, personalized care to the communities we serve.
Ascension is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care, including more than 140 hospitals and 40 senior living communities in 19 states.
Our Mission, Vision and Values encompass everything we do at Ascension. Every associate is empowered to give back, volunteer and make a positive impact in their community. Ascension careers are more than jobs; they are opportunities to enhance your life and the lives of the people around you.
**Equal Employment Opportunity Employer**
Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws.
For further information, view the EEO Know Your Rights (English) ( poster or EEO Know Your Rights (Spanish) ( poster.
As a military friendly organization, Ascension promotes career flexibility and offers many benefits to help support the well-being of our military families, spouses, veterans and reservists. Our associates are empowered to apply their military experience and unique perspective to their civilian career with Ascension.
Pay Non-Discrimination Notice ( note that Ascension will make an offer of employment only to individuals who have applied for a position using our official application. Be on alert for possible fraudulent offers of employment. Ascension will not solicit money or banking information from applicants.
**This Ministry does not participate in E-Verify and therefore cannot employ STEM OPT candidates.**

**Join the team at Crestwood Medical Center!**
Our benefits include:
+ Medical, dental, and vision coverage
+ 401(k) with employer match
+ Paid time off and holidays
+ Tuition assistance and reimbursement for approved programs
.and so much more to support your health, family, and future.
If you're ready to grow your career while making a difference, apply today to learn more!
**Job Summary**
The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.
**Essential Functions**
+ Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
+ Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices.
+ Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
+ Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
+ Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
+ Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
+ Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
+ Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
+ Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
+ Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
+ Performs other duties as assigned.
+ Complies with all policies and standards.
**Qualifications**
+ Associate Degree in Nursing, Health Information Management, or a related field required
+ Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
+ 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required
+ 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred
+ Experience in physician education or query processes preferred
+ Familiarity with regulatory standards and quality metrics related to clinical documentation preferred
**Knowledge, Skills and Abilities**
+ Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
+ Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
+ Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact).
+ Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
+ Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
+ Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
+ Commitment to maintaining compliance with regulatory standards and corporate policies.
**Licenses and Certifications**
+ RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required
+ CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
+ Certified Clinical Documentation Specialist (CCDS) preferred
+ RHIT - Registered Health Information Technician preferred or
+ RHIA - Registered Health Information Administrator preferred
+ CDIP - Clinical Documentation Improvement Professional preferred or
+ Certified Coder-AHIMA or AAPC preferred
INDNC
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to to obtain the main telephone number of the facility and ask for Human Resources.

**Job Summary**
The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.
**Essential Functions**
+ Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
+ Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices.
+ Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
+ Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
+ Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
+ Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
+ Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
+ Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
+ Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
+ Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
+ Performs other duties as assigned.
+ Complies with all policies and standards.
**Qualifications**
+ Associate Degree in Nursing, Health Information Management, or a related field required
+ Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
+ 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required
+ 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred
+ Experience in physician education or query processes preferred
+ Familiarity with regulatory standards and quality metrics related to clinical documentation preferred
**Knowledge, Skills and Abilities**
+ Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
+ Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
+ Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact).
+ Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
+ Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
+ Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
+ Commitment to maintaining compliance with regulatory standards and corporate policies.
**Licenses and Certifications**
+ RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
+ CCS-Certified Coding Specialist or ICD-10 certification or trainer designation required or
+ Certified Clinical Documentation Specialist (CCDS) required
+ RHIT - Registered Health Information Technician preferred or
+ RHIA - Registered Health Information Administrator preferred
+ CDIP - Clinical Documentation Improvement Professional preferred or
+ Certified Coder-AHIMA or AAPC preferred
INDNC
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to to obtain the main telephone number of the facility and ask for Human Resources.