Clinical Documentation Specialist Jobs

About The Position

Requirements

• Associate Degree in Nursing or a comparable clinical field required
• 5-7 years of acute care hospital clinical experience required
• 2-4 years of experience in clinical documentation improvement required
• Experience providing physician or provider education and mentoring CDI staff required
• DL NUMBER - Driver License, Valid and in State required
• RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required
• CDIP - Clinical Documentation Improvement Professional obtained within 6 months of hire date required or
• Certified Clinical Documentation Specialist (CCDS) obtained within 6 months of hire date required

Nice To Haves

• Bachelor's Degree in Nursing, Health Management, or a related field preferred
• Experience in critical care, case management, utilization review, quality, or inpatient coding preferred
• CDI leadership, lead, or supervisory experience preferred
• RHIT - Registered Health Information Technician preferred or
• RHIA - Registered Health Information Administrator preferred
• CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
• Certified Coder-AHIMA or AAPC preferred

Responsibilities

• Manages daily CDI operations and oversees documentation improvement activities to support accurate reflection of patient severity, acuity, and complexity of care.
• Monitors CDI operational performance, including key performance indicators, quality metrics, productivity, and documentation trends, and implements improvement strategies aligned with organizational goals.
• Provides education and guidance to providers and CDI staff regarding documentation practices, compliant query processes, coding guidelines, and regulatory requirements.
• Supervises CDI staff performance, including coaching, competency assessment, performance evaluation, onboarding, and professional development activities.
• Collaborates with coding, HIM, quality, care management, facility leadership, and clinical teams to support documentation integrity, reporting accuracy, reimbursement, and quality outcomes.
• Supports development and implementation of CDI workflows, tools, query templates, and operational processes in alignment with organizational standards.
• Analyzes clinical documentation and operational data to identify trends, risks, and opportunities for process improvement and performance enhancement.
• Participates in audits, compliance reviews, reporting activities, and regulatory readiness initiatives related to CDI operations.
• Maintains current knowledge of evolving coding guidelines, documentation standards, reimbursement methodologies, and regulatory requirements and communicates updates to stakeholders.
• Travels up to 50% to assigned facilities to support CDI operations, education, performance improvement initiatives, and operational alignment.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.