Clinical Documentation Specialist Job at CVS Health (Work at Home)

Clinical Documentation Specialist

We’re seeking a detail-oriented and collaborative Clinical Documentation Special...

Location

United States , Concord

Salary:

49.00 - 56.00 USD / Hour

Emerson Hospital

Expiration Date

Until further notice

Requirements

Bachelor of Science in Nursing (BSN) or Bachelor of Science in Biology or a related healthcare clinical program (e.g., Medical Records/Health Information Management)
3–5 years of acute care or equivalent clinical experience, or 3+ years of inpatient coding experience
Current Massachusetts Registered Nurse (RN) license and/or AHIMA coding certification (e.g., CCS, RHIT, RHIA) required
Ability to work independently and manage responsibilities with minimal supervision
Strong verbal and written communication skills
Proven ability to build effective working relationships with a wide range of healthcare providers
Team-oriented mindset with strong collaboration and information-sharing skills
Critical thinking and problem-solving abilities in complex clinical scenarios
Strong organizational skills with the ability to stay focused despite frequent interruptions
Proficiency with computer systems and ability to quickly learn new software applications

Job Responsibility

Review medical records to ensure accurate, complete, and compliant clinical documentation
Collaborate with physicians and care teams to clarify and improve documentation quality
Apply clinical and coding knowledge to support accurate code assignment and reimbursement
Facilitate documentation improvement initiatives in both concurrent and retrospective reviews
Educate providers and care teams on CMS regulations, documentation standards, and best practices
Partner with coding professionals to ensure alignment between documentation and coding outcomes
Support quality, compliance, and continuous improvement initiatives across the organization

What we offer

Competitive compensation and comprehensive benefits

Fulltime

Clinical Documentation Specialist

This role will facilitate the modifications of clinical documentation through ex...

Location

United States

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Graduate from an accredited school of nursing BSN
5 years relevant clinical experience
Clinical documentation improvement experience preferred
Current nursing license in the State of Illinois
Certification in clinical documentation improvement preferred
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills

Job Responsibility

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies
Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement
Demonstrate positive and effective interpersonal relations dealing with all members of the team

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Clinical Documentation Specialist

As a Clinical Documentation Integrity (CDI) Specialist, you will work under indi...

Location

United States , Centennial

Salary:

35.59 - 53.73 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Nursing Diploma or Associates Degree Required
Current RN license in state of employment or valid RN license from compact state, required
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
Self-motivated with excellent interpersonal, critical thinking, analytical, organizational, and writing skills
Sedentary work -(prolonged periods of sitting and exert up to 10lbs force occasionally)

Job Responsibility

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
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.

What we offer

Medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings

Fulltime

Clinical Documentation Specialist

This role will facilitate the modifications of clinical documentation through ex...

Location

United States

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Graduate from an accredited school of nursing BSN
5 years relevant clinical experience
Clinical documentation improvement experience preferred
Current nursing license in the State of Illinois
Certification in clinical documentation improvement preferred
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills

Job Responsibility

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies
Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement
Demonstrate positive and effective interpersonal relations dealing with all members of the team (i.e. co-workers, physicians, leadership, etc.)

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Opportunity for annual increases based on performance
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions

Fulltime

Senior Clinical Documentation Specialist (CDI)

Our client is seeking an experienced Senior Clinical Documentation Specialist (C...

Location

United States , Tampa

Salary:

35.00 - 50.00 USD / Hour

Medasource

Expiration Date

Until further notice

Requirements

Associate’s Degree in Nursing, Health Information Management (HIM), or a related healthcare field
Minimum 6 years of acute care Clinical Documentation Improvement (CDI) experience
Strong understanding of ICD-10-CM/ICD-10-PCS coding, Medicare/Medicaid/commercial payer guidelines, and clinical documentation improvement practices
Proven ability to independently develop compliant provider queries and collaborate directly with providers
Experience with at least two of the following: Optum 360 eCAC, Cerner EHR, Vizient
Strong inpatient CDI background
Strong written and verbal communication skills
Critical thinking and problem-solving ability
Ability to work independently in a remote environment

Job Responsibility

Review medical records for documentation quality, completeness, and accuracy
Identify gaps, conflicting documentation, and unspecified diagnoses
Develop compliant provider queries to improve documentation specificity
Ensure documentation accurately reflects severity of illness and risk of mortality
Collaborate directly with physicians and clinical staff through meetings, rounding, Zoom calls, phone calls, and email
Assist with provider education related to documentation improvement practices
Utilize clinical judgment, NLP tools, and CDI software platforms to support documentation review
Partner with HIM coding teams to support accurate reimbursement and reporting outcomes
Support onboarding and mentoring of junior CDI team members
Participate in operational and leadership-driven CDI initiatives and special projects

What we offer

100% remote work with flexible scheduling within EST business hours (Monday–Friday)
Strong long-term conversion potential for candidates in approved states
Collaborative, accountable, and supportive team environment
Competitive medical, dental, vision, Health Savings Account, Dependent Care FSA, and supplemental coverage options
401k plan with company match and full vesting upon eligibility
Paid time off, sick time, and paid company holidays
Opportunities for professional growth, mentoring, and special project involvement

Fulltime

Clinical Documentation Specialist RN

Improves the overall quality and completeness of clinical documentation by perfo...

Location

United States

Salary:

38.20 - 57.30 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

Graduate from an accredited school of nursing
BSN
5 years relevant clinical experience
Current nursing license in the State of Illinois
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills
Effective problem-solver with good interpersonal communication skills, verbal and written

Job Responsibility

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements
Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart
Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate
Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
Gather and analyze information pertinent to documentation findings and outcomes
Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

Fulltime

Clinical dermatology documentation specialist

OneForma is recruiting qualified medical professionals to participate in Project...

Location

United States

Salary:

Not provided

One Forma

Expiration Date

Until further notice

Requirements

Medical students (clinical years preferred)
Residents (Dermatology preferred
other specialties considered with relevant experience)
Licensed physicians (MD/DO or equivalent)
Submissions must demonstrate clinically accurate and realistic interactions
Submissions must demonstrate clear diagnostic reasoning
Submissions must demonstrate appropriate medical decision-making
Submissions must demonstrate professional, patient-centered tone
Submissions must demonstrate documentation consistent with U.S. clinical practice
All images must be fully de-identified

Job Responsibility

Create realistic, clinically accurate dermatology conversation threads formatted in a style similar to U.S. EPIC-style electronic health record documentation, adapted for patient portal messaging
Each submission must reflect an authentic patient encounter and include Chief concern
Each submission must reflect an authentic patient encounter and include Clinical assessment and reasoning
Each submission must reflect an authentic patient encounter and include Differential diagnosis (when appropriate)
Each submission must reflect an authentic patient encounter and include Management plan
Each submission must reflect an authentic patient encounter and include Follow-up recommendations
Threads may consist of Single-response exchanges (e.g., initial consult + physician response)
Threads may consist of Multi-turn conversations reflecting evolving clinical reasoning
All content must maintain a professional, patient-centered tone consistent with U.S. patient portal communication standards

Clinical Documentation Integrity Specialist

The Clinical Documentation Integrity Specialist (CDIS) facilitates the overall q...

Location

United States , West Covina

Salary:

69.00 USD / Hour

Emanate Health

Expiration Date

Until further notice

Requirements

Medical degree or Bachelor of Science in Nursing (BSN) preferred
Minimum of one (1) year of inpatient coding experience and/or experience working as a Clinical Documentation Integrity Specialist in an acute care setting
Strong knowledge of MS-DRG, APR-DRG, ICD-10-CM/PCS coding guidelines
Experience using encoder and electronic health record (EHR) systems
Excellent verbal and written communication skills
Strong analytical thinking, problem-solving abilities, and attention to detail
Proficiency in Microsoft Office applications preferred
ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within 1 year of hire/transfer

Job Responsibility

Facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team
Ensures that documentation accurately reflects the patient’s clinical conditions and level of service
Communicates with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses
Includes appropriate assignment of MS-DRG/APR-DRG, severity of illness (SOI), risk of mortality (ROM), and identification of relevant clinical indicators (e.g., HACs, PSIs)
Applies principles of clinical validation and ensures all queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics

Parttime

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Clinical Documentation Specialist

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