Source Job

US

  • Review inpatient and outpatient medical records to ensure accurate and compliant clinical documentation.
  • Collaborate with physicians and clinical teams to clarify diagnoses and support proper coding.
  • Maintain productivity targets and contribute to provider education initiatives to improve documentation quality.

Clinical Documentation ICD-10-CM CPT HCPCS

20 jobs similar to Clinical Documentation Specialist I

Jobs ranked by similarity.

US

  • Conduct coding audits to ensure accuracy and compliance with coding guidelines.
  • Identify compliance risks and recommend corrective action plans.
  • Provide education and training to physicians and staff on coding best practices.

Theoria Medical is at the forefront of healthcare innovation and quality, offering a blend of medical excellence and technological advancements, primarily serving the post-acute sector. Their network includes multispecialty physician services across skilled nursing facilities nationwide, fostering a mission-driven culture that values expertise and innovation.

US 3w PTO

  • Analyze and audit inpatient claims for DRG validation, coding accuracy, and clinical appropriateness without a medical record.
  • Utilize proprietary auditing systems to make determinations and generate audit letters, meeting productivity and quality standards.
  • Identify new claim types and suggest process improvements while maintaining expert ICD-10 and DRG coding knowledge.

Cotiviti is a healthcare analytics and auditing company that helps payers and providers improve financial performance and clinical outcomes. It is a large organization with a culture focused on accuracy, compliance, and collaboration.

US 4w PTO

  • Improve first-pass claim acceptance by ensuring correct coding, flagging inconsistencies, and reviewing EOBs and denial trends to identify recurring issues.
  • Work closely with billing teams and vendors to resolve complex claim issues, review clinical documentation, and support coding corrections and resubmissions.
  • Ensure compliance with CMS, state Medicaid, and managed-care guidelines while monitoring payer policy changes to optimize coding and billing practices.

ReKlame Health is a clinician-led, tech-enabled provider group providing culturally competent behavioral health and addiction care. As an early-stage organization focused on expanding access to care and health equity, they are building a purpose-driven team dedicated to making a positive impact.

US

  • Focuses on ensuring accuracy, compliance, and integrity of medical coding across healthcare records.
  • Conducts detailed audits, reviews clinical documentation, and identifies discrepancies impacting billing and compliance.
  • Collaborates with clinicians, revenue cycle teams, and leadership to improve documentation quality and coding consistency.

Jobgether is an AI-powered job matching platform that connects candidates with hiring companies. They process applications and share shortlists with employers, focusing on objective and fair review.

United States

  • Support payer audits and medical record reviews, ensuring timely submission of documentation.
  • Manage medical review requests and appeals associated with CMS contractors and regulatory agencies.
  • Review clinical documentation using audit checklists and partner with teams to gather required records.

VitalCaring is a provider of home health and hospice services founded in 2021. They are a growing company focused on quality and compliance, with a mission to deliver exceptional patient care.

US 40w PTO

  • Code inpatient services with 95% or above accuracy.
  • Abstract information from medical records to assign ICD-10 codes and identify query opportunities.
  • Collaborate with coding leads, billing, and CDI to resolve issues and ensure compliance with federal and state laws.

OHSU is Oregon's only public academic health center, providing patient care and leading groundbreaking research. As Portland's largest employer, it offers opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington.

$76,160–$112,000/yr
US

  • Audit behavioral health documentation and coding (ICD-10-CM and CPT) for accuracy, compliance, and completeness.
  • Deliver actionable feedback to providers, educating on coding and documentation guidelines.
  • Serve as a subject matter expert by answering coding-related questions and supporting internal teams.

Headway is building a new mental healthcare system from the ground up—one that’s accessible, effective, and built to scale. They have over 75,000 providers across all 50 states running their practice on their software, serving over 1 million patients.

US

  • Review and accurately code E/M cases for IP/OP/ER services to maximize reimbursement.
  • Meet daily production goals and maintain a 95% accuracy rate on a consistent basis.
  • Stay current on coding guidelines and maintain professional credentials, with flexibility to expand into other specialties.

Alteva RCM helps healthcare providers thrive through expert revenue cycle management and innovative solutions. The company fosters a collaborative culture focused on excellence and professional growth.

US 4w PTO

  • Review medical records and clinical documentation to ensure accurate, compliant coding per CMS, federal, state, and payer policies.
  • Conduct routine and focused coding audits, collaborate with clinical leadership and revenue cycle teams, and provide actionable recommendations.
  • Serve as a subject matter expert on pediatric, Medicaid, telehealth, and behavioral health coding, interpreting state-specific billing requirements.

Imagine Pediatrics is a tech-enabled, pediatrician-led medical group reimagining care for children with special health care needs. They deliver 24/7 virtual and in-home medical, behavioral, and social care, and are a remote-first, high-growth environment.

US

  • Review and validate all assigned OASIS assessments for accuracy, completeness, and internal consistency.
  • Code and sequence diagnoses per ICD-10 and CMS guidelines to ensure optimal reimbursement.
  • Provide clear, actionable feedback to field clinicians with a focus on education and process improvement.

Adaptive Home Health builds a higher-acuity, patient-centered home health model across Michigan. The company operates in a tech-forward environment with strong operational support.

US

  • Verify and analyze medical records to assign diagnostic and procedural codes using CMS guidelines.
  • Ensure accurate charge capture and data entry with a 95% accuracy rate.
  • Serve as a coding resource, resolve discrepancies, and assist in training new staff.

Munson Healthcare is northern Michigan's largest healthcare system with eight community hospitals serving over half a million residents. With a focus on excellence, teamwork, and community, they offer a supportive culture and a lifestyle in a beautiful region.

US Unlimited PTO 14w maternity 14w paternity

  • Conduct comprehensive MS-DRG and APR-DRG coding reviews to ensure accuracy in DRG assignment and reimbursement.
  • Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.
  • Craft clear, concise, and well-supported audit findings, backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations.

Cohere Health provides an AI-powered clinical intelligence platform that streamlines access to quality care by improving payer-provider collaboration and cost containment. The company works with over 660,000 providers, handles over 12 million prior authorization requests annually, and has been named to the Inc. 5000 list and a Top 5 LinkedIn Startup for 2023 and 2024.

$26–$39/hr
US

  • Accurately translate patients’ medical records into standardized codes for diagnoses and treatments.
  • Ensure compliance with legal, regulatory, and organizational standards.
  • Ensure claims are processed correctly and on time through clear communication and efficient management of records.

Dignity Health Medical Foundation provides comprehensive health care services. They have care centers throughout California and are affiliated with Dignity Health, one of the largest health systems in the nation. They strive to create purposeful work settings where staff can provide great care, while advancing in knowledge and experience through challenging work assignments and stimulating relationships.

US Unlimited PTO

  • Support ongoing documentation quality monitoring by reviewing provider notes for clinical completeness, risk, and payor compliance.
  • Serve as a clinical point of contact for providers, conducting outreach on documentation best practices and supporting a culture of quality.
  • Support complaint, grievance, and payor quality review workflows, including intake, clinical review, and resolution documentation.

Grow Therapy is a three-sided marketplace that empowers therapists, augments insurance payors, and serves patients, addressing the need for accessible mental healthcare. Since launching in February 2021, they have empowered over ten thousand therapists and hundreds of thousands of clients, raising over $328 million in funding at a $3 billion valuation from top investors.

Remote Coder

UASI
US

  • Perform accurate code assignments for ED records (facility and profee) while working remotely.
  • Be flexible, detail-oriented and have the ability to work independently.
  • Meet client productivity targets while maintaining coding quality of 95% or greater.

UASI is a company that values its employees! They have been awarded the Top Workplace award by the Cincinnati Enquirer in 2022 and 2023. Their 40 years in business contributes to the long tenure of their team.

US

  • Provides onsite and remote clinical documentation integrity support to CDI programs as part of the System Office CDI Float Pool.
  • Reviews and audits medical records to ensure accurate documentation of medical necessity, severity of illness, and level of services.
  • Trains end users on CDI software systems and communicates with healthcare teams to improve documentation practices.

Trinity Health is a large not-for-profit, faith-based health care system with 121,000 colleagues and nearly 36,500 physicians and clinicians serving communities across 27 states. The system includes 101 hospitals and invests heavily in community benefit programs.

US

  • Answer calls and resolve questions, routing to appropriate departments.
  • Complete documentation in EMR and marketing systems, including initial prescreening.
  • Schedule new and returning patients and complete follow-up duties.

Pyramid Healthcare provides addiction treatment, mental health recovery, and eating disorder treatment. They focus on client-centered care and offer supportive environments that help patients overcome life’s challenges.

US

  • Perform clinical reviews for medical necessity, level of care, and authorization-related denials.
  • Apply payer-specific guidelines and internal policies to support clear, defensible clinical narratives.
  • Meet assigned turnaround times and document findings accurately in designated systems.

CorroHealth helps clients exceed their financial health goals through scalable reimbursement solutions and clinical expertise, leveraging technology and analytics. The company builds long-term careers by investing in professional development and personal growth, fostering a culture of accountability and success.

Arizona

  • Monitor a specific group of patients and support them in achieving short and long term health goals.
  • Coordinate with providers to ensure patients' needs are met through remote monitoring technology.
  • Manage patient onboarding, device setup, data management, and quality assurance for remote monitoring programs.

Optima Medical is an Arizona-based medical group consisting of 30 locations and over 130 medical providers, caring for more than 200,000 patients statewide. Their mission is to help communities 'Live Better, Live Longer' through personalized healthcare, with a focus on preventing leading causes of death.

US Unlimited PTO

  • Responsible for accurate and timely assignment of ICD-10-CM/PCS and HCPCS/CPT codes for various record types.
  • Performs coding and abstracting to support billing, data quality, and severity-of-illness reporting.
  • Serves as a mentor to newer coders and works within service line structures as needed.

ChristianaCare is one of the largest health care providers in the Mid-Atlantic Region, operating hospitals in Delaware and Maryland. With over 1,100 beds and ANCC Magnet Recognition across its facilities, it is committed to delivering health through values of love and excellence.