Source Job

$41,600–$134,680/yr
US

  • Review patient records to improve quality and completeness of clinical documentation, ensuring accuracy for severity of illness and level of services.
  • Collaborate with providers, coders, and care team members to ensure comprehensive patient documentation and compliant documentation clarification.
  • Develop and deliver clinical documentation improvement education to providers, and monitor documentation requests to support revenue cycle integrity.

Clinical Documentation Medical Coding Regulatory Compliance

20 jobs similar to Clinical Documentation Specialist

Jobs ranked by similarity.

US

  • Manage day-to-day operations for the outpatient clinical documentation improvement program across multiple facilities.
  • Liaise with physicians and leadership on coding rules, risk adjustment, and reimbursement guidelines.
  • Ensure compliant and accurate medical record documentation while facilitating standardization.

Henry Ford Health is an academic health system providing comprehensive care across Michigan. With 12 hospitals and hundreds of clinics, it is a large organization focused on collaboration and innovation.

US

  • Ensure quality and completeness of medical record documentation through concurrent interaction with physicians and staff.
  • Facilitate modifications to clinical documentation to support accurate reimbursement and severity capture for inpatients.
  • Educate patient care team members on documentation best practices and support timely, accurate reporting.

Cooper University Health Care is a healthcare organization dedicated to providing extraordinary care through clinical innovation and advanced facilities. It offers a comprehensive benefits program and opportunities for career growth, with a team-oriented culture.

  • Serves as a subject matter expert in clinical documentation quality, risk adjustment, and HCC coding integrity.
  • Performs prospective reviews of medical records to validate chronic conditions and ensure documentation accuracy.
  • Utilizes Epic and OurPractice Advisories to support accurate coding, HCC capture, and compliance.

UASI is a clinical documentation improvement consulting firm dedicated to improving the quality and accuracy of clinical documentation. They offer a collaborative, mission-driven environment with opportunities for professional growth.

US

  • Orchestrate the flow of coded medical record information across inpatient and outpatient settings for billing accuracy.
  • Champion data quality by monitoring completeness, accuracy, and timeliness of medical documentation and coded submissions.
  • Design and deliver educational programs for clinical providers and coding staff on best practices, compliance, and documentation improvement.

Henry Ford Health is a leading academic health system providing a comprehensive continuum of care across Michigan and beyond. With 12 hospitals and hundreds of ambulatory locations, they foster a culture of purpose, collaboration, and belonging, empowering team members to grow their careers and make a meaningful difference.

$104,666–$150,613/yr
United States

  • Lead professional billing coding and clinical documentation integrity programs across a complex health system, ensuring coding accuracy and regulatory compliance.
  • Oversee team operations, including staffing, performance monitoring, audit education, and continuous process improvement.
  • Build strong relationships with executives, physicians, and coding professionals to drive quality and reimbursement integrity.

Jobgether is an AI-powered job matching platform that connects candidates with hiring companies. They use technology to review applications and share top-fitting candidates with employers, fostering an inclusive and efficient hiring process.

US

  • Provide real-time documentation support to healthcare providers before and after patient encounters.
  • Evaluate chart review performance and assist physicians in improving coding and documentation best practices.
  • Ensure compliance with federal and state laws related to coding and documentation guidelines for risk adjustment.

Interwell Health is a kidney care management company that partners with physicians to reimagine healthcare. They are mission-driven and value diversity, equity, and inclusion.

US

  • Provides oversight of CDI teams, ensuring optimal performance and adherence to compliant CDI practices and regulatory requirements.
  • Develops strategic plans to achieve enterprise KPIs and analyzes data to generate monthly performance reports for executive leadership.
  • Acts as a liaison between physicians, coding, and clinical quality to ensure accuracy and integrity of the inpatient medical record.

CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation’s largest nonprofit Catholic healthcare organizations, it has more than 157,000 employees and delivers over 20 million patient encounters annually.

$42–$42/hr
US

  • Conduct prospective chart reviews to validate ICD-10-CM and CPT coding accuracy.
  • Provide clinical documentation improvement feedback to providers on documentation gaps.
  • Ensure compliance with risk adjustment and regulatory coding guidelines.

Thyme Care is a cancer care navigation company transforming the cancer care experience through value-based care. They are building a diverse, mission-driven team to reshape the future of healthcare.

$125,000–$150,000/yr
United States Unlimited PTO 12w maternity 12w paternity

  • Help hospitals and health systems understand how AI-powered CDI can improve documentation, boost revenue, and drive quality care.
  • Work closely with Customer Success to refine documentation workflows and help clients maximize their CDI programs.
  • Communicate directly with client CDI leaders to establish trust, address concerns, and demonstrate advanced knowledge of inpatient clinical documentation best practices.

SmarterDx builds clinical AI to help hospitals achieve 100% chart accuracy for revenue integrity. The company is a remote-first team with a mission to make healthcare more accurate, sustainable, and effective for everyone.

US

  • Review and validate medical codes for diagnoses, procedures, and services to ensure accuracy and compliance with ICD-10, CPT, and HCPCS coding systems.
  • Provide expert coding guidance to clinicians and departments, serving as a resource for complex coding questions.
  • Conduct coding audits and quality reviews, generate productivity reports, and collaborate with IT and billing teams to resolve system issues.

Mission Healthcare is the largest home health and hospice company in the western United States, serving patients across seven states. The company fosters a culture of collaboration, compassion, and commitment, with core values of Compassion, Accountability, Respect, Excellence, and Service.

US

  • Review and assign diagnostic and procedural codes from medical records with 95% accuracy.
  • Serve as a liaison between billing and clinical sites to resolve coding discrepancies.
  • Train new employees and act as an expert resource for coding compliance questions.

Munson Healthcare is northern Michigan's largest healthcare system with eight award-winning community hospitals serving over half a million residents. They emphasize a culture of excellence, teamness, positivity, and creativity with over 5,000 employees.

US

  • Oversees CDI teams, ensuring optimal performance and compliance with regulatory requirements.
  • Develops strategic plans to achieve enterprise KPIs and analyzes data for monthly performance reports.
  • Acts as liaison between physicians, coding, and clinical quality to ensure accuracy of inpatient medical records.

CommonSpirit Health is a nonprofit Catholic healthcare organization delivering integrated health services. With over 157,000 employees, it is one of the nation's largest healthcare systems, focused on innovation and community care.

  • Abstracts and codes physician professional services using CPT and ICD-9 codes.
  • Provides documentation feedback to physicians and trains staff on billing and coding.
  • Resolves pre-accounts receivable edits and ensures charge capture through reconciliations.

Northwestern Medicine is a healthcare leader with a patient-first approach. They offer competitive benefits like tuition reimbursement, loan forgiveness, 401(k) matching, and lifecycle benefits, supporting a diverse team dedicated to better healthcare.

US

  • Review and interpret medical records to assign accurate ICD-10, CPT, and modifier codes for inpatient and outpatient encounters.
  • Collaborate with physicians and providers to resolve documentation gaps and strengthen coding accuracy.
  • Support audits, provider education, and revenue cycle performance through quality reviews and consistent productivity.

Jobgether uses AI-powered matching to connect candidates with hiring companies. They operate globally and focus on efficient recruitment through technology.

US

  • Review inpatient coding (ICD-10-CM/PCS) to ensure accuracy and completeness for multiple clients.
  • Validate DRG assignments and optimize reimbursement while maintaining compliance with regulatory standards.
  • Collaborate with service line teams and client departments to improve documentation and meet production goals.

Kodiak Solutions specializes in healthcare finance, unclaimed property, risk management, and revenue cycle management. They use technology-driven solutions to help healthcare organizations streamline operations and improve patient care.

Arizona

  • Review and assign accurate ICD-10-CM, CPT, and HCPCS codes based on clinical documentation.
  • Ensure coding compliance with CMS guidelines and state/federal regulations, and assist with claim reviews and audits.
  • Maintain up-to-date knowledge of coding guidelines and meet productivity and quality standards.

Optima Medical is an Arizona-based medical group with 30 locations and 130+ medical providers, caring for over 200,000 patients statewide. They offer a supportive culture with growth opportunities, a fun work environment, and comprehensive benefits.

US

  • Serve as the primary client relationship lead, ensuring alignment on goals, scope, deliverables, and outcomes.
  • Provide OP HCC CDI subject matter expertise and oversee project execution, quality, and client satisfaction.
  • Monitor project performance, manage risks and scope changes, and ensure successful delivery of contracted services.

UASI improves the quality and accuracy of clinical documentation through expert CDI consulting. We are a growing team with a collaborative, mission-driven environment that values continuous learning and professional growth.

US

  • Provide professional fee coding services across one or more medical specialties, accurately assigning codes.
  • Review clinical documentation and assign diagnosis and procedure codes to the highest level of specificity.
  • Work independently in a remote environment while maintaining required productivity and accuracy standards.

The company provides professional fee coding services across medical specialties. They seek a detail-oriented coding specialist to work independently in a remote environment.

US

  • Strategically coordinate and optimize the flow of coded medical record information to ensure accurate billing and reimbursement.
  • Review surgical coding submissions and manage denials to maximize revenue capture and compliance.
  • Design and deliver impactful educational programs that elevate documentation practices and coding quality.

Henry Ford Health is an academic health system providing comprehensive care across Michigan and beyond. With 12 hospitals and hundreds of ambulatory locations, the organization is a large, purpose-driven team committed to innovation and community impact.

US 3w PTO

  • Audit outpatient and specialty claims to ensure coding accuracy, clinical validity, and medical necessity.
  • Utilize advanced coding knowledge and audit tools to identify billing issues and document findings.
  • Meet productivity and quality standards while recommending process improvements and new claim types.

Cotiviti is a healthcare analytics and auditing company that focuses on improving claims accuracy and reducing costs for clients. They are a mid-to-large sized employer with a culture that emphasizes quality, collaboration, and innovation in healthcare auditing.