2,710 Healthcare Documentation Specialist jobs in the United States

Fully Remote : Clinical Documentation Specialist

Job Description

Facilitate the improvement of clinical documentation by collaborating with physicians, nursing staff, and other patient caregivers. Perform concurrent and retrospective reviews of medical records to ensure accurate documentation of patient care. Educate healthcare providers on the importance of accurate and complete clinical documentation. Utilize clinical knowledge and expertise to identify opportunities for documentation improvement. Ensure compliance with regulatory requirements and guidelines. Participate in multidisciplinary team meetings to discuss documentation improvement strategies. Provide feedback to healthcare providers on documentation practices and areas for improvement. Maintain up-to-date knowledge of clinical documentation standards and best practices.

Responsibilities

* Facilitate the improvement of clinical documentation by collaborating with physicians, nursing staff, and other patient caregivers.
* Perform concurrent and retrospective reviews of medical records to ensure accurate documentation of patient care.
* Educate healthcare providers on the importance of accurate and complete clinical documentation.
* Utilize clinical knowledge and expertise to identify opportunities for documentation improvement.
* Ensure compliance with regulatory requirements and guidelines.
* Participate in multidisciplinary team meetings to discuss documentation improvement strategies.
* Provide feedback to healthcare providers on documentation practices and areas for improvement.
* Maintain up-to-date knowledge of clinical documentation standards and best practices.

Qualifications

* Registered Nurse (RN) with a current license from any state.
* Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification.
* Certified Coding Specialist (CCS) certification if they have the CCDS 2 certification.
* Minimum of 3 years of clinical nursing experience.
* Strong knowledge of clinical documentation standards and regulatory requirements.
* Excellent communication and interpersonal skills.
* Ability to work collaboratively with healthcare providers and multidisciplinary teams.
* Proficiency in electronic health record (EHR) systems.

Additional Skills

* Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification.
* Certified Coding Specialist (CCS) certification if they have the CCDS 2 certification.

Work Environment

Fully remote role. Schedule: Monday-Friday 9am-5pm with potential for flexibility as long as 40-hour weeks are maintained.

Pay and Benefits

The pay range for this position is $7000.00 - $12000.00/yr.

Health, Vision, Dental, 401k

If we find a local candidate (CT RN license in CT, they will receive Middlesex Health Benefits, If we find someone national w/o CT RN License then they will receive benefits through 3rd party organization- Mindlance (have been told this is very expensive so they prefer local). Have all the benefit info in a PDF when needed

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on May 9, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email for other accommodation options.

**Details**
+ **Department:** Population Health Quality Department
+ **Schedule:** HYBRID Full-Time Day Shift
+ **Hospital:** Ascension Alexian Brothers - Ambulatory Services
+ **Location:** Elk Grove Village, IL
+ **Salary:** $79,059.75 - $110,204.85 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 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.
**Position has possibility to be hybrid with remote options. Remote employees must live/work in one of the following states:**
Alabama
Arizona
Arkansas
Colorado
Florida
Georgia
Idaho
Indiana
Iowa
Kansas
Kentucky
Louisiana
Missouri
Mississippi
Nebraska
New Mexico
North Carolina
Ohio
Oklahoma
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
West Virginia
Wyoming
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.

At Houston Methodist, the Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG's, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This role also facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.
**PEOPLE ESSENTIAL FUNCTIONS**
+ Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
**SERVICE ESSENTIAL FUNCTIONS**
+ Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department.
+ Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
**QUALITY/SAFETY ESSENTIAL FUNCTIONS**
+ Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
**FINANCE ESSENTIAL FUNCTIONS**
+ Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Identifies diagnoses and procedures performed and comorbidities and complications. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
**GROWTH/INNOVATION ESSENTIAL FUNCTIONS**
+ Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
**EDUCATION**
+ Associate's or bachelor's degree in nursing; OR
+ Medical School graduate where Western Medicine is practiced
**WORK EXPERIENCE**
+ For RN - At least five years of recent clinical experience caring for adults in an acute care hospital setting is required; coding and utilization review experience preferred
+ For Medical School graduate - One year of clinical experience preferred
**LICENSES AND CERTIFICATIONS - REQUIRED**
+ RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days **OR**
+ RN-Temp - Registered Nurse - Temporary State Licensure within 60 days
+ CCDS - Clinical Documentation Specialists (ASDIS) -- For Medical School graduate **OR**
+ CDIP - Certified Documentation Integrity Practitioner (AHIMA) -- For Medical School graduate **OR**
+ CCS - Certified Coding Specialist (AHIMA) -- For Medical School graduate
**KNOWLEDGE, SKILLS, AND ABILITIES**
+ Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
+ Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
+ Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
+ Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
+ Demonstrates accountability and professional development
+ Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
+ Regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.
**SUPPLEMENTAL REQUIREMENTS**
**WORK ATTIRE**
+ Uniform No
+ Scrubs No
+ Business professional Yes
+ Other (department approved) No
**ON-CALL***
_*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below._
+ On Call* No
**TRAVEL***
_**Travel specifications may vary by department**_
+ May require travel within the Houston Metropolitan area No
+ May require travel outside Houston Metropolitan area No
**Company Profile:**
Houston Methodist is one of the nation's leading health systems and academic medical centers. Houston Methodist consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. Houston Methodist also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, Houston Methodist employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide high quality patient care.
Houston Methodist is 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.
+ 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
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
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
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.

**REQUIRED:**
+ **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**
**What We Offer**
+ Health Insurance Eligibility 1st of the month following 30 days of employment for full and part time employees
+ Tuition Reimbursement & SoFi Student Loan Repayment Plans
+ 3% 401k Employer Matching
+ Company Provided Renewal of BLS, ACLS & PALS
**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
INDNUR
To apply, please email
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.

At Houston Methodist, the Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG's, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This role also facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.
**PEOPLE ESSENTIAL FUNCTIONS**
+ Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
**SERVICE ESSENTIAL FUNCTIONS**
+ Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department.
+ Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
**QUALITY/SAFETY ESSENTIAL FUNCTIONS**
+ Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
**FINANCE ESSENTIAL FUNCTIONS**
+ Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Identifies diagnoses and procedures performed and comorbidities and complications. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
**GROWTH/INNOVATION ESSENTIAL FUNCTIONS**
+ Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
**EDUCATION**
+ Associate's or bachelor's degree in nursing; OR
+ Medical School graduate where Western Medicine is practiced
**WORK EXPERIENCE**
+ For RN - At least five years of recent clinical experience caring for adults in an acute care hospital setting is required; coding and utilization review experience preferred
+ For Medical School graduate - One year of clinical experience preferred
**LICENSES AND CERTIFICATIONS - REQUIRED**
+ RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days **OR**
+ RN-Temp - Registered Nurse - Temporary State Licensure within 60 days
+ CCDS - Clinical Documentation Specialists (ASDIS) -- For Medical School graduate **OR**
+ CDIP - Certified Documentation Integrity Practitioner (AHIMA) -- For Medical School graduate **OR**
+ CCS - Certified Coding Specialist (AHIMA) -- For Medical School graduate
**KNOWLEDGE, SKILLS, AND ABILITIES**
+ Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
+ Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
+ Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
+ Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
+ Demonstrates accountability and professional development
+ Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
+ Regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.
**SUPPLEMENTAL REQUIREMENTS**
**WORK ATTIRE**
+ Uniform No
+ Scrubs No
+ Business professional Yes
+ Other (department approved) No
**ON-CALL***
_*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below._
+ On Call* No
**TRAVEL***
_**Travel specifications may vary by department**_
+ May require travel within the Houston Metropolitan area No
+ May require travel outside Houston Metropolitan area No
**Company Profile:**
Houston Methodist is one of the nation's leading health systems and academic medical centers. Houston Methodist consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. Houston Methodist also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, Houston Methodist employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide high quality patient care.
Houston Methodist is an Equal Opportunity Employer.