Clinical Documentation Specialist

University Hospitals

Clinical Documentation Specialist ensuring accurate clinical documentation and provider education. Focused on improving risk profiles and billing processes through expert analysis.

Posted 5/27/2026full-timeRemote • Ohio • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels
Assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity
Focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs)
Complete pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices
Coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation

Requirements

What you’ll need

High School Equivalent / GED (Required)
Associate's Degree (Preferred)
3+ years Coding and/or clinical documentation integrity (Required)
Extensive clinical knowledge and understanding of pathophysiology (Required proficiency)
Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record (Required proficiency)
Excellent written and verbal communication skills (Required proficiency)
Strong project management skills (Required proficiency)
Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization (Required proficiency)
Ability to work independently in a time-oriented environment (Required proficiency)
Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency)
Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency)
Ability to build education material that is meaningful for providers and team members (Required proficiency)
Strong problem solving and investigative skills (Required proficiency)

Benefits

Comp & perks

Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines
Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

codingclinical documentation integritypathophysiologyclinical indicatorsmedical record clarificationproject managementelectronic medical recordseducation material developmentproblem solvinginvestigative skills

Soft Skills

critical thinkingwritten communicationverbal communicationinterpersonal skillsindependent worktime management

Certifications

High School Equivalent / GEDAssociate's Degree