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Clinical Documentation Specialist - Acute Care Experience Preferred

Northwell · Posted Apr 6, 2026

Open

Lake Success, New York, United States
1–3 years

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Clinical Documentation Specialist - Acute Care Experience Preferred

Northwell · Posted Apr 6, 2026

Open

Lake Success, New York, United States
1–3 years

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Senior Hospital Clinical Documentation Improvement Specialist

Capital Health (US) · Posted Nov 2, 2026

Open

Lawrenceville, New Jersey, United States
On-site
Full-time · Senior
$90K–$118K per year
3+ years

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Responsible for optimizing the accuracy, completeness, and clinical integrity of provider documentation. Performs a second level review aimed at improving clinical documentation, coding accuracy and DRG optimization.

Compensation

Pay Range: $90,480.00 - $118,227.20

Responsibilities

Serves as key resource in CDI operational performance, quality initiatives, and organizational documentation improvement strategy
Performs advanced second-level reviews of medical records to optimize the accuracy, completeness, and clinical integrity of provider documentation and identify trends to identify gaps in documentation and training opportunities
Conducts in-depth reviews prior to final billing of target case populations, place queries if documentation opportunities are identified, and collaborate with the coding team on coding opportunities
Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed. Proactively identifies issues with reporting of diagnostic testing
Collaborates with CDI leadership to review trends related to DRG downgrades, query activity, and revenue cycle opportunities to inform educational content and strategic planning for CDI, HIM Coding, or Provider audiences

Requirements

RN
Graduate of an accredited school of nursing program

Lead Clinical Documentation Improvement - Hybrid

Community Health Systems · Posted Nov 3, 2026

Open

Tucson, Arizona, United States
On-site
Competitive compensation
4–6 years

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Lead Clinical Documentation Improvement (CDI) providing advanced support for clinical documentation activities across assigned facilities to ensure accuracy, completeness, and integrity of clinical documentation.

Responsibilities

Lead and support facility-level CDI activities
Perform complex clinical documentation reviews
Facilitate provider education and feedback
Collaborate with coding, HIM, quality, care management, and clinical teams
Monitor and report CDI key performance indicators

Requirements

Associate Degree in Nursing
Nice to have: Bachelor's Degree in Nursing, Health Information Management, or related field
Nice to have: ICU/Critical Care experience
Nice to have: case management
Nice to have: utilization review

Skills

ICD-10-CM/PCS coding MS-DRG/APR-DRG methodologies CDI software encoder tools electronic medical records standard office software

Lead Clinical Documentation Improvement

Community Health Systems · Posted Nov 3, 2026

Open

Laredo, Texas, United States
Hybrid
Full-time · Lead
4–6 years

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The Clinical Documentation Improvement (CDI), Lead provides advanced support for clinical documentation improvement activities across assigned facilities to ensure the accuracy, completeness, and integrity of clinical documentation. This role supports compliant documentation practices that reflect patient severity, acuity, and quality outcomes while promoting accurate coding, reimbursement, and regulatory compliance.

Responsibilities

Leads and supports facility-level CDI activities to promote accurate clinical documentation reflecting patient severity, acuity, and complexity of care.
Performs complex clinical documentation reviews and provides guidance, mentoring, and operational support to CDI team members.
Facilitates provider education and feedback regarding documentation opportunities, query practices, and clinical documentation improvement initiatives.
Collaborates with coding, HIM, quality, care management, and clinical teams to support accurate data reporting, reimbursement, and quality outcomes.
Monitors and reports CDI key performance indicators, trends, and outcomes to facility and corporate stakeholders.

Requirements

Associate Degree in Nursing
International MD
RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license
Nice to have: Bachelor's Degree in Nursing
Nice to have: Health Information Management

Skills

acute care hospital nursing experience

Clinical Documentation Specialist I

Cleveland Clinic · Posted Nov 3, 2026

Open

Remote, United States
Remote
Intern
5+ years

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Provide education to providers and clinicians to ensure accurate clinical documentation and coding compliance.

Responsibilities

Provide education to providers and clinicians
Review clinical records for correct DRG, APC, HCC assignment
Query providers for diagnostic specificity
Maintain accurate review records in CDI software
Meet daily review and query response targets

Requirements

High School Diploma/GED
Nice to have: Associate’s Degree in healthcare-related field
Nice to have: Registered Nurse (RN)
Nice to have: Certified Clinical Documentation Specialist (CCDS or CCDS-O)

Skills

ICD10-CM CPT HCC HCPCS Med Surg ICU ER PSI CDI knowledge

Clinical Documentation Specialist - Acute Care Experience Preferred

Clinical Documentation Specialist - Acute Care Experience Preferred

Compensation

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Senior Hospital Clinical Documentation Improvement Specialist

Compensation

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Requirements

Lead Clinical Documentation Improvement - Hybrid

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Lead Clinical Documentation Improvement

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Clinical Documentation Specialist I

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CDI software jobs

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