• HIM Retrospective Clinical Documentation

    Penn Medicine (Philadelphia, PA)
    Documentation Specialist will oversee organization-wide system for improving clinical documentation in the medical record. Plan, organize, design, implement ... RHIT or CCS Required Skills and Abilities Strong knowledge of MS-DRG's and medical record documentation requirements are essential Ability to analyze complex… more
    Penn Medicine (06/17/25)
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  • Coding and Documentation Educator

    AdventHealth (Lees Summit, MO)
    …provider education experience. **The value you'll bring to the team:** + Analyze medical record documentation for HCC accuracy, correct documentation , and ... providers regarding the need for accurate, specific, and complete clinical documentation in the patient's medical record. + Serve as a subject matter expert in… more
    AdventHealth (06/17/25)
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  • Clinical Documentation Specialist (Remote)

    Trinity Health (Livonia, MI)
    …consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review. Through ... physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of… more
    Trinity Health (07/25/25)
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  • Director Clinical Documentation Integrity

    Tufts Medicine (Burlington, MA)
    …duties: Facilitates improvement in overall quality, completeness, and accuracy of medical record documentation , obtains appropriate clinical documentation ... and leaders. The Director oversees the manager and clinical documentation specialists (CDSs) in planning, implementing improvements, and re-evaluating processes… more
    Tufts Medicine (07/04/25)
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  • RN - Senior Clinical Documentation

    Sanford Health (Bemidji, MN)
    …case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and ... related group (DRG). Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the designated… more
    Sanford Health (07/22/25)
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  • Documentation Specialist | 40 hours per…

    Great River Health (West Burlington, IA)
    …resolves discrepancies-Communication with providers face to face or via clinical documentation inquiries regarding missing, unclear or conflicting medical record ... are responsible for improving overall quality and completeness of clinical documentation by inpatient providers. CDI facilitates modifications to documentation more
    Great River Health (06/25/25)
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  • Clinical Documentation Specialist Auditor-…

    UNC Health Care (Chapel Hill, NC)
    …Educates CDS, physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate ... records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality.… more
    UNC Health Care (07/29/25)
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  • Clinical Documentation Specialist

    LifePoint Health (Johnstown, PA)
    …physicians, case managers, coders, and other health care team members, the Clinical Documentation Specialist will strive to ensure comprehensive medical record ... patients each year through the Conemaugh Physician Group and Medical Staff, a network of hospitals, specialty clinics, and...to all members of the health care team on documentation guidelines, this position will provide guidance and support,… more
    LifePoint Health (07/24/25)
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  • Clinical Documentation Specialist (Full…

    Queen's Health System (Honolulu, HI)
    …clinical documentation throughout The Queen's Health Systems, through concurrent medical records reviews and query process. * Responsible for the concurrent ... and all members of patient care teams to ensure the integrity of medical record documentation and allow for accurate and complete medical record coding. II.… more
    Queen's Health System (07/10/25)
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  • Clinical Documentation Specialist

    Ascension Health (Elk Grove Village, IL)
    …**Responsibilities** Facilitate improvement in overall quality, completeness and accuracy of medical record documentation . + Complete admission reviews and ... in the medical record and to resolve physician queries and documentation issues prior to patient's discharge. + Maintain accurate records of review activities,… more
    Ascension Health (07/31/25)
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