Entry Level Clinical Documentation Improvement Jobs
New grad clinical documentation improvement jobs welcome recent graduates and entry level candidates with zero to two years of experience, where strong internship work or a CDI certification often carries more weight than a long resume. Most openings mix on-site and remote settings across Healthcare & Medical Services, with employers like SSM Health, Genesis HealthCare, and Yale New Haven Health hiring at this level now.
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See related jobsPOSITION PURPOSE:
The purpose of the Clinical Documentation Improvement (CDI) Analyst position is to advance clinical documentation integrity through a combination of concurrent review, data analytics, and informatics workflow optimization. This role ensures the accuracy, completeness, and usability of clinical documentation to support quality outcomes, regulatory compliance, reimbursement optimization, and organizational performance within the Critical Access Hospital environment.
QUALIFICATIONS:
-
Graduation from an accredited healthcare program required
Bachelor’s degree in Healthcare, Health Information Management, Nursing, or related field preferred
Current valid healthcare license (or compact license), RHIA, RHIT, or equivalent credential preferred
CDI certification (CCDS or CDIP) required or willingness to obtain within an established timeframe
Additional certification in informatics, data analytics, quality, or healthcare compliance preferred
Working knowledge of clinical documentation standards, coding principles, reimbursement methodologies, quality reporting, and regulatory requirements
Strong analytical, critical thinking, communication, and problem-solving skills
Experience with Electronic Health Records (EHR), reporting systems, and healthcare analytics tools preferred, preferably Oracle Health/Cerner
GENERAL REQUIREMENTS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The requirements listed below are representative of the knowledge, skill, and / or ability required:
Ability to add, subtract, multiply, and divide
Ability to generate, read, interpret, and take action as it relates to basic financial statements, national and state regulations, safety rulings, operational and maintenance and organizational policies / procedures
Ability to write reports and correspondence
Ability to effectively present information to patients, families, employees, health care providers, etc...
Ability to work cooperatively and communicate effectively to maintain good working relationships with staff and health care providers
Ability to work with skill in identifying problems; making frequent decisions regarding method of performance
EQUIPMENT, TOOLS, MATERIALS:
Calculator
Computer and printer
Fax and copy machine
General office materials/supplies
Information Systems
Telephone system
SECURITY/ACCESS:
Will have access to the facility 24 hours a day.
Will have access to confidential information abiding by the organizations privacy policies and regulations concerning this information.
Essential Job Duties and Responsibilities
1. Provides clinical documentation improvement services through concurrent and retrospective review of patient records to ensure accurate, complete, and compliant clinical documentation.
- Performs concurrent and retrospective review of inpatient, swing bed, observation, and other applicable encounters.
- Identifies opportunities to improve documentation specificity, severity of illness, risk of mortality, and overall clinical accuracy.
- Initiates, tracks, and manages compliant provider queries with a focus on clinical clarity and documentation integrity.
- Collaborates directly with providers to ensure timely and accurate documentation of patient conditions, treatments, and outcomes.
- Reviews documentation for consistency, completeness, and compliance with established documentation standards.
- Serves as the organizational subject matter expert for clinical documentation integrity, documentation standards, and best practices.
- Works collaboratively with coding, quality, and clinical teams to ensure documentation accurately reflects the care provided.
2. Provides advanced analytics, reporting, and performance monitoring to evaluate and improve the effectiveness of the Clinical Documentation Improvement program.
- Leads the development, maintenance, and ongoing enhancement of DA2 (Data Abstraction and Analytics) reporting tools.
- Designs, develops, and maintains dashboards that monitor key CDI, quality, and documentation performance indicators.
- Analyzes documentation trends, opportunities, and gaps to identify areas for improvement.
- Assists with documentation-related quality measure requirements and reporting initiatives.
- Performs root cause analysis of documentation, coding, and data integrity variances.
- Translates data findings into actionable recommendations for providers, leadership, quality, and operational teams.
- Prepares and presents CDI performance reports to leadership, quality, informatics, and revenue cycle stakeholders.
- Monitors and evaluates the impact of documentation practices on quality reporting, regulatory reporting, and organizational performance.
3. Provides leadership and support for documentation-related workflow optimization, system design, and clinical informatics initiatives.
- Serves as the CDI lead for EHR documentation workflow design, optimization, and standardization efforts.
- Develops, maintains, and refines electronic query workflows, templates, tracking tools, and documentation resources.
- Collaborates with Information Technology and Clinical Informatics teams to improve documentation workflows, reporting accuracy, and data capture.
- Evaluates and recommends enhancements to CDI software, encoder functionality, reporting tools, and documentation systems.
- Ensures integrity and consistency of documentation-related data across EHR, coding, quality, billing, and reporting platforms.
- Participates in system upgrades, testing activities, workflow redesign initiatives, and implementation of documentation-related technologies.
4. Provides education, consultation, and program development to promote documentation integrity and continuous improvement
- Develops and delivers targeted education to providers, clinical staff, and leadership based on documentation trends and identified opportunities.
- Identifies ongoing documentation improvement opportunities through routine monitoring and data analysis.
- Assists with the development, implementation, and maintenance of CDI policies, procedures, and program standards.
- Provides consultation and guidance regarding documentation best practices and regulatory expectations.
- Promotes a culture of documentation integrity, accountability, and continuous improvement throughout the organization.
5. Provides compliance and regulatory oversight related to clinical documentation integrity activities. Ensures billing practices comply with HIPAA, CMS guidelines, payer contract requirements, and applicable federal and state regulations.
- Ensures CDI practices align with CMS guidance, industry standards, coding guidelines, and regulatory requirements.
- Supports organizational audit readiness and serves as a resource during internal and external reviews.
- Monitors regulatory and industry changes impacting documentation practices and CDI operations.
- Recommends and implements process improvements necessary to maintain compliance and program effectiveness.
- Assists with organizational efforts related to documentation compliance, quality initiatives, and regulatory reporting.
6. Follows HIPAA regulations and ensures that the confidentiality of patients medical, personal, financial records, employee records, and organizational records is maintained.
7. Participates in FCH committees, quality assurance, performance and quality improvement initiatives, and activities which support the facility and department operations.
8. Complies with the state and federal regulatory requirements related to the performance of FCH operations and requirements of the FCH Compliance Program. Including but not limited to:
- The Compliance Policy.
- Completes all on-line training annually and as assigned.
- All department and organization-wide policies.
- Considers the impact of regulations such as Critical Access Hospital requirements, along with Federal and State of Nebraska regulations and discusses concerns appropriately to ensure compliance.
9. Presents self in a professional manner and enhances professional growth and development through participation in education programs, current literature, in-service meetings and workshops.
Seeks opportunities for continued growth and performance improvement.
Always maintains a professional appearance and manner.
Dependable and completes work in a timely manner.
Demonstrates an understanding and emphasis on quantity, quality and knowledge of duties and tasks
10. Performs other duties as assigned.
Essential Standards of Service Excellence
1. Abides by Fillmore County Hospital's C.A.R.E Service Standards which include:
C- COMMUNICATE WITH COMPASSION, COURTESY & CLARITY We create trust through respectful, professional communication. Greet, Listen, Respect. Greet everyone with eye contact, a smile, and a warm, professional tone. Use the six-foot rule to greet anyone within proximity. Listen actively. Allow others to finish speaking, seek to understand, and respond thoughtfully. Speak honestly and respectfully. Refrain from sarcasm, gossip, or undermining comments. Represent FCH positively. Concerns are addressed privately, not in front of patients or visitors. Praise often and in public. Protect the privacy and confidentiality of all patients and coworkers. Apologize sincerely when appropriate. Manage up during all handoffs and thank patients for choosing FCH.
A- ASSIST EVERY PERSON, EVERY TIME We go beyond tasks to meet needs with empathy and urgency. See a need, meet a need. Offer help before being asked; never walk past someone who needs assistance. Escort patients and visitors who appear unsure or need direction. Acknowledge delays, explain what to expect, and thank people for their patience. Follow through on commitments and promises.
R- RESPECT EACH OTHER & OUR ENVIRONMENT We treat every individual and every space with dignity and care. Calm space, caring place. Treat all people with kindness, fairness, and compassion. Maintain a calm, quiet, healing environment. Your demeanor sets the tone. Show respect for cultural, personal, and professional differences. Keep work areas clean, safe, and organized. Clean up after yourself. Protect hospital equipment and property; return items to the proper place. Bring issues forward respectfully and constructively, through appropriate reporting channels.
E- EXCEL THROUGH TEAMWORK & PROFESSIONALISM We choose behaviors that strengthen our team and uphold our mission. Solutions, not excuses. Be dependable. Show up ready, on time, and prepared for the day. Support coworkers. Offer help and ask for help appropriately. Maintain professionalism during stressful or emergent situations. Bring solutions, not just problems. Contribute to a positive, problem-solving culture. Model professional ‘onstage’ behavior in all public and patient-facing areas. Dress in a professional manner. Use a complaint as an opportunity to improve. Choose to maintain a positive, solution-focused attitude.
2. Abides by Fillmore County Hospitals Core Values which include:
Teamwork
Respect
Integrity
Compassion
ESSENTIAL WORK ENVIRONMENT & PHYSICAL REQUIREMENTS:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
POSITION PURPOSE:
The purpose of the Clinical Documentation Improvement (CDI) Analyst position is to advance clinical documentation integrity through a combination of concurrent review, data analytics, and informatics workflow optimization. This role ensures the accuracy, completeness, and usability of clinical documentation to support quality outcomes, regulatory compliance, reimbursement optimization, and organizational performance within the Critical Access Hospital environment.
QUALIFICATIONS:
-
Graduation from an accredited healthcare program required
Bachelor’s degree in Healthcare, Health Information Management, Nursing, or related field preferred
Current valid healthcare license (or compact license), RHIA, RHIT, or equivalent credential preferred
CDI certification (CCDS or CDIP) required or willingness to obtain within an established timeframe
Additional certification in informatics, data analytics, quality, or healthcare compliance preferred
Working knowledge of clinical documentation standards, coding principles, reimbursement methodologies, quality reporting, and regulatory requirements
Strong analytical, critical thinking, communication, and problem-solving skills
Experience with Electronic Health Records (EHR), reporting systems, and healthcare analytics tools preferred, preferably Oracle Health/Cerner
GENERAL REQUIREMENTS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The requirements listed below are representative of the knowledge, skill, and / or ability required:
Ability to add, subtract, multiply, and divide
Ability to generate, read, interpret, and take action as it relates to basic financial statements, national and state regulations, safety rulings, operational and maintenance and organizational policies / procedures
Ability to write reports and correspondence
Ability to effectively present information to patients, families, employees, health care providers, etc...
Ability to work cooperatively and communicate effectively to maintain good working relationships with staff and health care providers
Ability to work with skill in identifying problems; making frequent decisions regarding method of performance
EQUIPMENT, TOOLS, MATERIALS:
Calculator
Computer and printer
Fax and copy machine
General office materials/supplies
Information Systems
Telephone system
SECURITY/ACCESS:
Will have access to the facility 24 hours a day.
Will have access to confidential information abiding by the organizations privacy policies and regulations concerning this information.
Essential Job Duties and Responsibilities
1. Provides clinical documentation improvement services through concurrent and retrospective review of patient records to ensure accurate, complete, and compliant clinical documentation.
- Performs concurrent and retrospective review of inpatient, swing bed, observation, and other applicable encounters.
- Identifies opportunities to improve documentation specificity, severity of illness, risk of mortality, and overall clinical accuracy.
- Initiates, tracks, and manages compliant provider queries with a focus on clinical clarity and documentation integrity.
- Collaborates directly with providers to ensure timely and accurate documentation of patient conditions, treatments, and outcomes.
- Reviews documentation for consistency, completeness, and compliance with established documentation standards.
- Serves as the organizational subject matter expert for clinical documentation integrity, documentation standards, and best practices.
- Works collaboratively with coding, quality, and clinical teams to ensure documentation accurately reflects the care provided.
2. Provides advanced analytics, reporting, and performance monitoring to evaluate and improve the effectiveness of the Clinical Documentation Improvement program.
- Leads the development, maintenance, and ongoing enhancement of DA2 (Data Abstraction and Analytics) reporting tools.
- Designs, develops, and maintains dashboards that monitor key CDI, quality, and documentation performance indicators.
- Analyzes documentation trends, opportunities, and gaps to identify areas for improvement.
- Assists with documentation-related quality measure requirements and reporting initiatives.
- Performs root cause analysis of documentation, coding, and data integrity variances.
- Translates data findings into actionable recommendations for providers, leadership, quality, and operational teams.
- Prepares and presents CDI performance reports to leadership, quality, informatics, and revenue cycle stakeholders.
- Monitors and evaluates the impact of documentation practices on quality reporting, regulatory reporting, and organizational performance.
3. Provides leadership and support for documentation-related workflow optimization, system design, and clinical informatics initiatives.
- Serves as the CDI lead for EHR documentation workflow design, optimization, and standardization efforts.
- Develops, maintains, and refines electronic query workflows, templates, tracking tools, and documentation resources.
- Collaborates with Information Technology and Clinical Informatics teams to improve documentation workflows, reporting accuracy, and data capture.
- Evaluates and recommends enhancements to CDI software, encoder functionality, reporting tools, and documentation systems.
- Ensures integrity and consistency of documentation-related data across EHR, coding, quality, billing, and reporting platforms.
- Participates in system upgrades, testing activities, workflow redesign initiatives, and implementation of documentation-related technologies.
4. Provides education, consultation, and program development to promote documentation integrity and continuous improvement
- Develops and delivers targeted education to providers, clinical staff, and leadership based on documentation trends and identified opportunities.
- Identifies ongoing documentation improvement opportunities through routine monitoring and data analysis.
- Assists with the development, implementation, and maintenance of CDI policies, procedures, and program standards.
- Provides consultation and guidance regarding documentation best practices and regulatory expectations.
- Promotes a culture of documentation integrity, accountability, and continuous improvement throughout the organization.
5. Provides compliance and regulatory oversight related to clinical documentation integrity activities. Ensures billing practices comply with HIPAA, CMS guidelines, payer contract requirements, and applicable federal and state regulations.
- Ensures CDI practices align with CMS guidance, industry standards, coding guidelines, and regulatory requirements.
- Supports organizational audit readiness and serves as a resource during internal and external reviews.
- Monitors regulatory and industry changes impacting documentation practices and CDI operations.
- Recommends and implements process improvements necessary to maintain compliance and program effectiveness.
- Assists with organizational efforts related to documentation compliance, quality initiatives, and regulatory reporting.
6. Follows HIPAA regulations and ensures that the confidentiality of patients medical, personal, financial records, employee records, and organizational records is maintained.
7. Participates in FCH committees, quality assurance, performance and quality improvement initiatives, and activities which support the facility and department operations.
8. Complies with the state and federal regulatory requirements related to the performance of FCH operations and requirements of the FCH Compliance Program. Including but not limited to:
- The Compliance Policy.
- Completes all on-line training annually and as assigned.
- All department and organization-wide policies.
- Considers the impact of regulations such as Critical Access Hospital requirements, along with Federal and State of Nebraska regulations and discusses concerns appropriately to ensure compliance.
9. Presents self in a professional manner and enhances professional growth and development through participation in education programs, current literature, in-service meetings and workshops.
Seeks opportunities for continued growth and performance improvement.
Always maintains a professional appearance and manner.
Dependable and completes work in a timely manner.
Demonstrates an understanding and emphasis on quantity, quality and knowledge of duties and tasks
10. Performs other duties as assigned.
Essential Standards of Service Excellence
1. Abides by Fillmore County Hospital's C.A.R.E Service Standards which include:
C- COMMUNICATE WITH COMPASSION, COURTESY & CLARITY We create trust through respectful, professional communication. Greet, Listen, Respect. Greet everyone with eye contact, a smile, and a warm, professional tone. Use the six-foot rule to greet anyone within proximity. Listen actively. Allow others to finish speaking, seek to understand, and respond thoughtfully. Speak honestly and respectfully. Refrain from sarcasm, gossip, or undermining comments. Represent FCH positively. Concerns are addressed privately, not in front of patients or visitors. Praise often and in public. Protect the privacy and confidentiality of all patients and coworkers. Apologize sincerely when appropriate. Manage up during all handoffs and thank patients for choosing FCH.
A- ASSIST EVERY PERSON, EVERY TIME We go beyond tasks to meet needs with empathy and urgency. See a need, meet a need. Offer help before being asked; never walk past someone who needs assistance. Escort patients and visitors who appear unsure or need direction. Acknowledge delays, explain what to expect, and thank people for their patience. Follow through on commitments and promises.
R- RESPECT EACH OTHER & OUR ENVIRONMENT We treat every individual and every space with dignity and care. Calm space, caring place. Treat all people with kindness, fairness, and compassion. Maintain a calm, quiet, healing environment. Your demeanor sets the tone. Show respect for cultural, personal, and professional differences. Keep work areas clean, safe, and organized. Clean up after yourself. Protect hospital equipment and property; return items to the proper place. Bring issues forward respectfully and constructively, through appropriate reporting channels.
E- EXCEL THROUGH TEAMWORK & PROFESSIONALISM We choose behaviors that strengthen our team and uphold our mission. Solutions, not excuses. Be dependable. Show up ready, on time, and prepared for the day. Support coworkers. Offer help and ask for help appropriately. Maintain professionalism during stressful or emergent situations. Bring solutions, not just problems. Contribute to a positive, problem-solving culture. Model professional ‘onstage’ behavior in all public and patient-facing areas. Dress in a professional manner. Use a complaint as an opportunity to improve. Choose to maintain a positive, solution-focused attitude.
2. Abides by Fillmore County Hospitals Core Values which include:
Teamwork
Respect
Integrity
Compassion
ESSENTIAL WORK ENVIRONMENT & PHYSICAL REQUIREMENTS:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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- Healthcare & Medical Services
Entry Level Clinical Documentation Improvement Jobs: Frequently Asked Questions
How do I get an entry level clinical documentation improvement job?
Employers hiring at the entry level typically look for a clinical background in nursing, health information management, or a related field, combined with familiarity with ICD-10 coding and DRG concepts. Completing a CDI certification through ACDIS or AHIMA gives candidates a concrete edge. Highlighting any clinical rotations, coding coursework, or hands-on chart review experience shows readiness even without a long work history.
Which companies hire entry level clinical documentation improvements?
Companies hiring entry level clinical documentation improvements right now include SSM Health, Genesis HealthCare, and Yale New Haven Health, based on current listings on Migrate Mate as of August 2026. Hiring at this level comes from a broad mix of health systems, acute-care hospitals, remote CDI staffing firms, and health information management organizations actively building out junior teams.
Are these new grad clinical documentation improvement jobs?
Yes, these listings include new grad, recent graduate, and junior clinical documentation improvement roles. A posting is generally new-grad friendly when it welcomes zero to two years of experience, accepts internships or clinical rotations in lieu of full employment history, or calls out a CDI certificate or coding coursework as a substitute for on-the-job experience. Look for language like 'will train' or 'entry level welcome' as reliable signals.
Which industries hire the most entry level clinical documentation improvements?
Entry Level clinical documentation improvement roles concentrate in Healthcare & Medical Services, based on current listings on Migrate Mate as of August 2026. These sectors drive hiring at the junior level because they operate high-volume inpatient facilities where accurate clinical documentation directly affects reimbursement, quality scores, and regulatory compliance, creating steady demand for new specialists.