Clinical Documentation Improvement Specialist

Lake Regional Health System

Clinical Documentation Improvement Specialist reviewing patient documentation for accuracy. Responsible for improving clinical documentation quality and facilitating education for healthcare providers.

Posted 7/14/2026full-timeRemote • Ohio • 🇺🇸 United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Documentation Improvement (CDI) with a strong focus on ICD and CPT coding guidelines, ensuring accurate and complete clinical documentation to optimize reimbursement. Possesses the ability to educate healthcare providers and collaborate effectively with multidisciplinary teams to enhance documentation quality and compliance.

Highest-signal resume keywords

Clinical Documentation Improvement (CDI)ICD & CPT Coding GuidelinesCertified Clinical Documentation Specialist (CCDS)Certified Professional Coder (CPC)Medical Terminology Training

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewCoding Guidelines KnowledgeHealthcare Documentation ComplianceRevenue Cycle ExperienceHCC Coding RequirementsMedical Record Content KnowledgeAnatomy and Physiology TrainingCoding/Classification Systems KnowledgeDocumentation Quality ImprovementPatient Care Team Education

Soft Skills

Effective CommunicationCollaborationProblem SolvingActive ListeningEducation and Training

Tools & Technologies

Coding Software (Encoders)Quality Measures KnowledgeLDC/NCD Knowledge

Certifications & Qualifications

Certified Documentation Expert Inpatient (CDEI)Certified Clinical Documentation Specialist (CCDS)Certified Professional Coder (CPC)Certified Coding Specialist (CCS)

Industry Keywords

Clinical DocumentationPatient RecordsHealthcare ComplianceMulti-Facility OperationsAlternate Payment Models

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 ICD and CPT Coding Guidelines.
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 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.
Three to five years CDI experience preferred.
Must possess a certification; Certified Documentation Expert Inpatient (CDEI), Certified Clinical Documentation Specialist (CCDS), or Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with coding or clinical documentation integrity experience.
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.

Benefits

Comp & perks

Health insurance
401(k) matching
Flexible working hours
Paid time off
Professional development opportunities