Clinical Documentation Specialist
Johns Hopkins Medicine
Clinical Documentation Specialist | Special Projects | Remote Full-Time | 40 hr/week | Day Shifts | Fully Remote This role focuses on leading and supporting strategic Clinical Documentation Improvement (CDI) initiatives to enhance the accuracy, quality, and compliance of clinical documentation. The position involves collaborating with physicians, nurses, coders, IT, and leadership to identify documentation gaps, implement solutions, and optimize electronic health record (EHR) use. Key responsibilities include conducting detailed chart reviews, performing clinical validation, supporting documentation improvement efforts, and tracking/reporting data to measure project success. The role also provides education to staff and providers, assists with policy development, and offers coverage during high-demand periods. Education: Requires successful completion of: Baccalaureate degree, or associates degree, or diploma in nursing from an accredited school of Nursing OR Successful completion of an AMA approved Physician Assistant program, OR Successful completion of the academic requirements of Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM ) Require Licensure Certification, etc.: Required to maintain the certification as a Certified Clinical Documentation Specialist (CCDS via ACDIS) or Certified Documentation Integrity Practitioner (CDIP via AHIMA) RN/APRN: Must possess a current RN compact (multi-state) license in the state in which you reside. If your state or the Johns Hopkins Health System location in which you are assigned does not participate in the Nurse Licensure compact, an RN license for that state in which you are assigned will be required. PA: Must possess current licensure to practice as a Physician Assistant (PA) in the state in which you reside and be board-certified by the National Commission on Certification of Physician Assistants (NCCPA). If your state of the Johns Hopkins Health System location in which you are assigned does not participate in the PA Licensure Compact, a license for the state in which you are assigned will be required. RHIT.RHIA: Requires successful completion of the academic requirements for the Registered Health Information Technician (RHIT) certification or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and be a Certified Coding Specialist (CCS). Work Experience Registered Nurse (RN): Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of complex acute care experience, at least 6 years of CDI experience and/or other relevant clinical experience may be considered. Physician Assistant (PA): Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of complex acute care experience, at least 6 years of CDI experience and/or other relevant clinical experience may be considered. RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of acute inpatient coding, at least 6 years of CDI experience and/or relevant clinical experience may be considered. What Awaits You: Competitive pay and benefits that support you at every stage of your life and career. Retirement plans with employer contributions to help you plan confidently for the future. Generous time off so you can unplug, recharge, and enjoy life outside of work. Access to world-class facilities and innovative technology that fuel your curiosity. Endless opportunities to advance your career as part of the Johns Hopkins team Salary Range: Minimum 45.28/hour - Maximum 74.76/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority. The Hospital reserves the right to modify employee schedules as needed. We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices. Johns Hopkins Health System and its affiliates are drug-free workplace employers. #J-18808-Ljbffr
$86k
...POSITION SUMMARY: Possesses strong clinical foundation with respect to differential... ...terminologies Educates provides on clinical documentation best practices aligned with ICD-10-CM/... ...ACDIS Certified Clinical Documentation Specialist (CCDS) AHIMA Certified Coding...SuggestedFull timeShift work$33.26 - $49.88 per hour
...in Robbinsdale and Maple Grove as well as a network of 23 clinics which includes 13 primary clinics, 6 specialty clinics, 4 urgent... ...acts of implicit bias. About this position The Clinical Documentation Specialist facilitates modifications to clinical documentation through...SuggestedFull timeContract workPart timeFor contractorsFor subcontractorWork at officeRemote workShift work$78k - $96.2k
Job Title: Clinical Documentation Specialist Department: Clinical Documentation Improvement Location: Unity Hospital (Remote) Hours Per Week: 40 hours per week Schedule: Monday- Friday 8 hr. shifts. SUMMARY: The role facilitates accurate documentation for severity of illness...SuggestedFull timeTemporary workRemote workMonday to FridayShift work- ...insurance Note : Eligibility for benefits may vary by location and is determined by employment status Job Summary The Clinical Documentation Specialist provides clinically based concurrent and retrospective review of inpatient Medicare medical records to evaluate the...SuggestedFlexible hours
- Beyond Blue Job Posting Title: Inpatient Clinical Documentation Specialist II Requisition Number: R-000003831 Department Name: Supervisor, Inpatient Clinical Documentation Work Location: Remote-KY Grade Level: 11 Type of Position: Regular Position Time Status: Full time...SuggestedFull timePart timeWork experience placementReliefInternshipRemote workShift work
$32.5 - $44 per hour
...Full time Weekly Hours: 40.00 Salary Range: $32.50 - $44 Department Details We are seeking a compassionate and skilled Clinical Documentation Specialist to join our dedicated care team. This CDS position is part of a seasoned team that readily support each other. Once...Full timePart timeWork experience placementWork at officeRemote workWork from homeShift workDay shift- Job Summary The Clinical Documentation Excellence Specialist (CDES) is a pivotal role. The role works closely with providers and healthcare teams to enhance clinical documentation accuracy and ensure ICD-10 coding precision. Your efforts will help us deliver the highest...Work at office
- St. Elizabeth HealthCare in Kentucky is seeking a qualified nursing professional to conduct reviews of physician documentation to enhance clinical documentation practices. The role requires a compassionate approach with all patients, families, and staff, ensuring dignity...
- Confluence Health is seeking a clinically skilled professional to review and improve patient health records for accurate coding and reimbursement... ...with providers and coding teams to ensure high-quality documentation and patient outcomes. #J-18808-Ljbffr Confluence Health
- Valley Hospital Medical Center is seeking a registered nurse to perform clinically based concurrent and retrospective reviews of inpatient medical records. The role aims to ensure appropriate documentation of care, reflect patient severity of illness, and support accurate...
- Rochester Regional Health is seeking a Clinical Documentation Specialist to optimize documentation for severity of illness and quality. You will review records, coordinate with physicians, and drive CDS workflow across departments. The role requires an RN background with...Remote jobShift work
- Oak Street Health is seeking a Medical Scribe to support our primary care providers with clinical documentation. You will observe and document patient encounters, assign CPT/ICD-10 codes, and help prepare After Visit Summaries in a team-based clinic environment. This full...Full time
- Moffitt Cancer Center in Tampa, FL is seeking a Clinical Documentation Specialist Senior to lead documentation improvement for provider-based records, with oncology focus and advanced coding expertise. You will train staff, collaborate with physicians, and ensure documentation...
- Nacogdoches Medical Center in East Texas is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient Medicare records to ensure accurate documentation of illness severity and appropriate reimbursement. The role requires an...
- ...DESCRIPTION AND POSITION REQUIREMENTS Scheduled Weekly Hours: TBD WORK SHIFT: 8:00 AM - 4:30 PM (MON - FRI) JOB SUMMARY: The Clinical Documentation Specialist (CDS) facilitates the improved integrity of medical record documentation through interaction with healthcare providers...Remote jobReliefWork at officeShift work
- UMC Health System is seeking a Clinical Documentation Specialist (CDS) to perform concurrent reviews of active patient records and to query the medical staff for complete documentation that supports illness severity and mortality risk. The CDS relies on nursing expertise...Shift work
- North Memorial Health seeks a Clinical Documentation Specialist to collaborate with physicians and care teams to ensure accurate coding and appropriate severity for inpatient services. This role emphasizes documentation accuracy and team-based improvement across a major...Remote job
- ...driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting. As we continue to grow our... ...experienced and motivated Clinical Risk Adjustment Documentation Specialists to join our dedicated team in a fully remote capacity. As...Remote work
$5,000 - $7,000 per month
...Neurology & Physical Medicine team as a Physician Extender / Clinical Assistant. This is a full-time outpatient position in a fast... ...attending physician with patient evaluations, examinations, documentation, and follow-up management for neurologic and musculoskeletal...Full timeWork at office- ...regulations. Information Retrieval and Communication : Retrieve and deliver records as needed, assist with inquiries, and prepare documentation for insurance, Medicare, Medicaid, and other stakeholders. Journey offers all care team members the Journey Advantage which...Local areaHome office
$29 - $30 per hour
...confidentiality Support record retention and storage procedures Monitor documentation for completeness and notify appropriate staff of deficiencies... ...information management tasks Communicate effectively with clinical staff, residents, families, and outside agencies as...Full timeReliefLocal area- ...accuracy Collaborating with Pre‑Litigation Paralegals and medical records providers, using independent discretion to obtain necessary documents Managing medical liens Utilizing software such as ChartSwap, Needles, and other legal/medical records platforms Key...Full timeWork at office
- Non-Clinical - Admin Shift: 07:00 AM - 07:00 PM Shifts Per Week: 3 Scheduled Hours: 36 Start Date: 08/24/2026 End Date: 10/31/2026 Duration: 10 Week(s) Location: 760 Broadway, Brooklyn, NY, 11206 PSNYCShift work
- ...Clinical Administrator Flu Vaccination Event Date: Thursday, October 13th Time: 11:00 am - 4:30 pm Position Overview The admin will report prior to the start of the event at the assigned time to ensure all needed supplies are onsite and that the location...Work at office
- ...for an accommodation or an alternative application process. Clinical Reviewer Full Time Professional Houston, TX, US 2 days ago Requisition... ...records, clinical histories, assessments, and referral documentation to determine clinical appropriateness and program fit. This...Full time
$75k - $90k
...for an accommodation or an alternative application process. Clinical Reviewer - Portland, Oregon 5 days ago Requisition ID: 1126... ...services at the right time? In this role, you will review clinical documentation to determine medical necessity and appropriateness of...Full timeContract workRemote workWork from home- ...Clinical Abstractor, Infant Mortality Action Team (IMAT) The Fund for Public Health in New York City (FPHNYC) is a 501(c)3 non-profit organization dedicated to the advancement of the health and well-being of all New Yorkers. In partnership with the New York City Department...Contract workTemporary workPart timeLive inWork at officeRemote work
$42k - $52k
...in the world. The Role Performs operational duties in support of regulatory and/or Good Manufacturing Practice (GMP) compliance documentation; coordinating the verification, approval, and processing of document revisions; and tracking document activity to ensure timeliness...Full timeWork at officeLocal areaRemote workRelocationShift work- ...P&E Constructors, LLC is seeking a meticulous Document Controller to manage project documentation across the lifecycle on nationwide assignments. You will organize drawings, specifications, and transmittals and ensure revisions are current for project teams. The role...Daily paid
- ...Luster National, Inc. is seeking a Document Control Specialist to support large, heavy-civil infrastructure projects across highways, bridges, transit, aviation, and water sectors. You will manage the flow, accuracy, and organization of project documentation, ensure version...For contractors
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