Clinical Documentation Specialist

Quorum Health

Clinical Documentation Specialist providing inpatient medical record reviews for healthcare quality, ensuring compliant coding and documentation integrity support across clinical teams.

Posted 7/9/2026full-timeRemote • California, Kentucky, Massachusetts, Nevada, New Mexico, Oregon, Tennessee, Texas, Utah, Wyoming • 🇺🇸 United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Documentation Improvement (CDI) with a strong understanding of ICD-10-CM/PCS coding guidelines, MS-DRG methodology, and quality reporting standards. Engages effectively with clinical and coding teams to ensure accurate documentation and compliance with healthcare regulations.

Highest-signal resume keywords

Clinical Documentation Improvement (CDI)ICD-10-CM/PCS Coding GuidelinesMS-DRG MethodologyInpatient Coding ExperienceCCDS or CDIP Certification

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewQuality ReportingCoding ComplianceCritical ThinkingClinical ReasoningProvider Query SubmissionDocumentation AccuracyRisk of Mortality AssessmentSeverity of Illness EvaluationDenials Prevention

Soft Skills

Effective CommunicationCollaborationEducation DeliveryInterpersonal SkillsProactive Engagement

Certifications & Qualifications

CCDSCDIPRHIARHITCCS

Industry Keywords

Inpatient Medical RecordsHealthcare AdministrationUtilization ReviewRevenue Cycle ManagementAHA Coding Clinic

About the role

Key responsibilities & impact

Provides clinically based, concurrent and retrospective reviews of inpatient medical records.
Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to support compliant coding, reimbursement, quality reporting, and denials prevention initiatives.
Proactively contacts physicians or other clinicians as needed to clarify procedures/diagnoses to ensure proper documentation.
Performs initial case reviews and follow up reviews.
Submits compliant provider queries as needed to clarify documentation of relevant diagnoses, procedures, clinical indicators, present-on-admission status, acuity, specificity, and treatment in accordance with ACDIS/AHIMA compliant query guidance and organizational policy.
Applies knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, MS-DRG/APR-DRG methodology, CC/MCC capture, SOI/ROM, and quality indicators to support an accurate working DRG in collaboration with Coding/HIM.
Promotes a partnership with Coding/HIM team to ensure the accuracy of principal diagnosis, procedures, and completeness of documentation to determine the working and final DRG, severity of illness and risk of mortality.
Functions as a liaison between clinical and coding teams.
Actively engages and participates in delivery of education to providers through extensive interaction one on one.
Utilizes critical thinking skills and clinical reasoning to identify, clarify, and query accurate representation of documentation to reflect appropriate clinical status of the patient which will translate into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.

Requirements

What you’ll need

Bachelor’s degree in Nursing, Health Information Management, healthcare administration, or related healthcare field preferred.
Associate degree/diploma, allied health education, or equivalent professional credential may be considered with demonstrated CDI, clinical, coding, or HIM experience.
2-5 years acute care clinical, inpatient coding, HIM, quality, utilization review/case management, or revenue cycle experience preferred.
Inpatient CDI experience and knowledge of IPPS, MS-DRGs, CC/MCCs, SOI/ROM, HAC/PSI, and denials prevention preferred.
Current unrestricted RN, LPN/LVN, or other applicable clinical license required only when candidate is hired under that clinical credential.
RHIA, RHIT, CCS, CCDS, CDIP, MD/DO/MBBS, foreign medical graduate, or other qualified healthcare/coding credential may be considered when supported by demonstrated clinical documentation and coding knowledge.
CCDS or CDIP preferred and encouraged; experienced CDI Specialists should obtain CCDS or CDIP within 24 months of meeting eligibility requirements or hire, unless otherwise approved by CDI leadership.

Benefits

Comp & perks

Competitive salary and benefits package.
Opportunities for professional development and advancement.
Supportive work environment with a collaborative team.
Comprehensive healthcare coverage.
Retirement savings plan.
Paid time off and flexible scheduling options.
Student loan repayment program.