Clinical Documentation Specialist

Sutter Health

Clinical Documentation Specialist ensuring accuracy and completeness of clinical documentation for patient care quality at Sutter Health. Collaborating with physicians and patient teams to optimize documentation outcomes.

Posted 5/20/2026full-timeRemote • California, Louisiana, Texas, Utah, Washington • 🇺🇸 United StatesMid-LevelSenior💰 $39 - $109 per hourWebsite

About the role

Key responsibilities & impact

Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care.
Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation.
Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.

Requirements

What you’ll need

Graduate of an accredited school of nursing OR Foreign trained physician
RN-Registered Nurse of California OR Foreign trained physician
CCDS or CDIP certification
5 years recent relevant experience.
Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications.
Knowledge of age-specific needs and the elements of disease processes and related procedures.
Knowledge of current coding classification and reimbursement guidelines and regulations.
Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries.
Ability to define issues, collect data, establish facts and draw valid conclusions.
Demonstrates a proactive approach in identifying and addressing issues and concerns.
Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome.
Displays a customer service focus in all decisions and actions.
Ability to communicate through verbal and written means, and to present information to a variety of audiences.
Ability to create and translate data into reports and presentations for appropriate audience.
Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness.
Ability to interact and maintain effective working relationships with those contacted in the performance of required duties.
Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment.
Demonstrates initiative in providing feedback/input to improve workflow/processes.
Ability to work effectively in a dynamic and fast-paced environment with changing business priorities.
Ability to maintain and work discreetly with confidential information.
Ability to use essential applications and/or databases associated with the role’s duties and responsibilities.

Benefits

Comp & perks

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical documentationmedical record reviewcoding classificationreimbursement guidelinesdata analysisreport creationpresentation skillsdiagnoses knowledgeseverity of illness assessmentrisk of mortality evaluation

Soft Skills

critical thinkingcollaborationcustomer service focuscommunicationorganizationinitiativeproactive approachinterpersonal skillsproblem-solvingadaptability

Certifications

RN-Registered Nurse of CaliforniaCCDSCDIP