Outpatient Clinical Documentation Improvement Specialist

Lake Regional Health System

Outpatient Clinical Documentation Improvement Specialist improving clinical documentation for patient records. Engaging with healthcare providers to ensure accurate documentation and compliance with coding guidelines.

Posted 6/24/2026full-timeRemote • Ohio • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation.
Should have a comprehensive understanding of Coding Guidelines and are responsible for clarifying conflicting, incomplete, or imprecise documentation by actively seeking answers and actively educating providers.
Work to continuously improve clinical documentation to best reflect the care provided and corresponding reimbursement.
Responsible for improving the overall quality and completeness of clinical documentation.
Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and Physician Practice Coding staff to support that appropriate reimbursement, clinical severity of illness, and risk of mortality is captured for the level of service rendered to all patients.
Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and practice outcomes.
Educates all members of the patient care team on an ongoing basis.

Requirements

What you’ll need

Must have an Associate’s degree in Healthcare, Nursing or related field, or equivalent combination of education & experience.
Must have training in medical terminology, anatomy, and physiology.
Must have training and certification in coding, or equivalent combination of education and experience.
Must possess a certification; Certified Documentation Expert Outpatient (CDEO), Certified Clinical Documentation Specialist-Outpatient (CCDS-O), or Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with coding or clinical documentation integrity experience.
Must agree to obtain CDEO or CCS-O within first year of employment.
In-depth knowledge of medical record content.
In-depth knowledge of coding/classification systems (ICD & CPT) and associated coding guidelines.
Experience with compliant healthcare documentation, HCC coding requirements, alternate payment models in a multi-facility, revenue cycle experience.
Basic computer skills.
Should be knowledgeable in use of coding software (encoders).
Should be knowledgeable in LDC/NCD (or how to look this up) and Quality Measures.
Should be knowledgeable in coding guidelines.
Requires excellent observation skills, analytical thinking, problem solving, plus excellent verbal/ written and presentation skills.
Must have the ability to balance and juggle multiple tasks, projects, and requests; meet deadlines.
Ability to communicate effectively via remote Teams application.
Manual and finger dexterity.
Sitting for extended periods of time.
Ambulate to provider practices or group meetings, as needed.
Requires corrected vision and hearing to normal range.
Requires working under stressful conditions.
Excellent interpersonal skills in dealing with co-workers, providers, physicians and their office staff, Practice Mangers, and other Work Areas.

Benefits

Comp & perks

Health insurance
Retirement plans
Paid time off
Flexible work arrangements
Professional development opportunities

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical terminologyanatomyphysiologycodingICDCPTHCC codingclinical documentation integritycoding guidelinesrevenue cycle

Soft Skills

observation skillsanalytical thinkingproblem solvingverbal communicationwritten communicationpresentation skillstime managementmultitaskinginterpersonal skillsstress management

Certifications

Certified Documentation Expert Outpatient (CDEO)Certified Clinical Documentation Specialist-Outpatient (CCDS-O)Certified Professional Coder (CPC)Certified Coding Specialist (CCS)