Clinical Documentation Specialist

Cleveland Clinic

Clinical Documentation Specialist providing documentation education and compliance review for Cleveland Clinic's healthcare system. Ensuring accurate medical records and coding in patient care processes.

Posted 5/30/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Provide education to providers and clinicians for accurate clinical documentation
Review for correct DRG, APC, and HCC assignment
Adhere to industry standards for documentation and coding compliance
Maintain a record of review and query activity in CDI software
Conduct reviews of medical records in outpatient settings
Educate providers on optimal documentation and coding

Requirements

What you’ll need

High School Diploma/GED or equivalent
Five years of experience as clinical nurse, inpatient or outpatient coder OR two years of experience as a Clinical Documentation Integrity Specialist
Associate’s Degree in healthcare-related field (preferred)
Registered Nurse (RN) in the current state of employment (preferred)
ICD10-CM, CPT, HCC, and HCPCS inpatient or outpatient coding experience (preferred)

Benefits

Comp & perks

Endless support and appreciation
Build a rewarding career
Comply with influenza prevention program
Equal opportunity employer

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

ICD10-CMCPTHCCHCPCSclinical documentationcoding compliancemedical record reviewoutpatient codinginpatient codingquery activity

Soft Skills

educationcommunicationattention to detailorganizational skillsinterpersonal skills

Certifications

Registered Nurse (RN)High School Diploma/GEDAssociate’s Degree in healthcare-related field