Clinical Documentation Specialist Jobs
Clinical Documentation Specialist jobs are open across hospitals, health systems, physician groups, and long-term care facilities, at every level from entry-level to senior and lead, with specializations in inpatient coding, outpatient documentation, and clinical documentation improvement. Find a role that fits from the openings below and apply directly.
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At UASI, we're driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting. As we continue to grow our service offerings, we're looking for experienced and motivated OP Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity.
As an Outpatient Clinical Documentation Improvement (CDI) Specialist, this individual will play a critical role in supporting coding accuracy, HCC capture, regulatory compliance, and clinical documentation integrity. This role requires strong clinical judgment, analytical skills, and a commitment to advancing documentation excellence that reflects the patient's true severity of illness and complexity of care.
Key Responsibilities
- Serves as a subject matter expert in clinical documentation quality, risk adjustment, and HCC coding integrity in the outpatient setting.
- Performs prospective reviews of medical records from physician practices, outpatient settings, and relevant inpatient encounters to validate chronic conditions and ensure documentation accuracy, clinical integrity, appropriate coding, and HCC capture.
- Utilizes Epic, OurPractice Advisories (OPAs) to perform prospective chart reviews, identify documentation opportunities, validate chronic conditions, and support accurate coding, HCC capture, and clinical documentation integrity initiatives.
- Track and manage work queues, review inventories, and OPA-related activities to ensure timely follow-up, productivity targets, and accurate completion of CDI interventions.
- Monitor, analyze, and report CDI outcomes, documentation trends, and HCC recapture performance to identify improvement opportunities and support program goals.
Qualifications:
- Minimum 2 years of ambulatory Clinical Documentation Integrity, Risk Adjustment, or related healthcare documentation experience
- Active LPN or RN license required
- CCDS, CCDS-O, CDIP, CDEO and/or CRC certification strongly preferred
- Proficiency in Epic workflows, including interpretation and management of OurPractice Advisories (OPAs) preferred
- Strong understanding of: ICD-10-CM coding guidelines, HCC documentation and coding requirements
- Strong understanding of clinical criteria for HCC diagnoses
- Excellent communication, critical thinking, and organizational skills.
- Comfortable using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing tools (MS Teams, Zoom, etc.).
Why UASI?
We believe that investing in our people is key to our success. In return for your talents, we offer a full benefits package, PTO and top pay! Additional benefits include:
- Collaborative, mission-driven team environment.
- Opportunities for continuous learning, education and professional growth.
- Leadership that values your expertise and input
Ready to make a difference and grow your career? We would love to hear from you!
At UASI, we're driven by a mission to improve the quality and accuracy of clinical documentation through expert CDI consulting. As we continue to grow our service offerings, we're looking for experienced and motivated OP Clinical Documentation Improvement (CDI) professionals to join our dedicated team in a fully remote capacity.
As an Outpatient Clinical Documentation Improvement (CDI) Specialist, this individual will play a critical role in supporting coding accuracy, HCC capture, regulatory compliance, and clinical documentation integrity. This role requires strong clinical judgment, analytical skills, and a commitment to advancing documentation excellence that reflects the patient's true severity of illness and complexity of care.
Key Responsibilities
- Serves as a subject matter expert in clinical documentation quality, risk adjustment, and HCC coding integrity in the outpatient setting.
- Performs prospective reviews of medical records from physician practices, outpatient settings, and relevant inpatient encounters to validate chronic conditions and ensure documentation accuracy, clinical integrity, appropriate coding, and HCC capture.
- Utilizes Epic, OurPractice Advisories (OPAs) to perform prospective chart reviews, identify documentation opportunities, validate chronic conditions, and support accurate coding, HCC capture, and clinical documentation integrity initiatives.
- Track and manage work queues, review inventories, and OPA-related activities to ensure timely follow-up, productivity targets, and accurate completion of CDI interventions.
- Monitor, analyze, and report CDI outcomes, documentation trends, and HCC recapture performance to identify improvement opportunities and support program goals.
Qualifications:
- Minimum 2 years of ambulatory Clinical Documentation Integrity, Risk Adjustment, or related healthcare documentation experience
- Active LPN or RN license required
- CCDS, CCDS-O, CDIP, CDEO and/or CRC certification strongly preferred
- Proficiency in Epic workflows, including interpretation and management of OurPractice Advisories (OPAs) preferred
- Strong understanding of: ICD-10-CM coding guidelines, HCC documentation and coding requirements
- Strong understanding of clinical criteria for HCC diagnoses
- Excellent communication, critical thinking, and organizational skills.
- Comfortable using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing tools (MS Teams, Zoom, etc.).
Why UASI?
We believe that investing in our people is key to our success. In return for your talents, we offer a full benefits package, PTO and top pay! Additional benefits include:
- Collaborative, mission-driven team environment.
- Opportunities for continuous learning, education and professional growth.
- Leadership that values your expertise and input
Ready to make a difference and grow your career? We would love to hear from you!
Clinical Documentation Specialist Jobs by Experience Level
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Find JobsClinical Documentation Specialist Job Market
Who's Hiring
Top Industries Hiring
- Healthcare & Medical Services47
- Biotechnology & Pharmaceuticals5
- Education2
- Government & Public Sector2
- Consulting & Professional Services2
What Employers Look For
The qualifications that appear most often in clinical documentation specialist jobs.
- RHIA, RHIT, CDIP, or CCDS certification strongly preferred or required
- Proficiency in ICD-10-CM and ICD-10-PCS coding guidelines
- Experience reviewing clinical records and drafting compliant physician queries
- Familiarity with electronic health record systems such as Epic or Cerner
- Knowledge of MS-DRG methodology and reimbursement implications
- Minimum two to three years of clinical documentation or coding experience
Tips for Your Clinical Documentation Specialist Job Search
Highlight CDI certifications prominently on your resume
Recruiters scanning clinical documentation specialist resumes look for CDIP or CCDS credentials near the top. List your certifying body, credential, and year earned in a dedicated credentials section, not buried in a skills list.
Quantify your query resolution and denial impact
Generic phrases like 'improved documentation quality' won't stand out. Replace them with concrete outcomes: the volume of physician queries you managed weekly, your response rate, or how your work reduced claim denials for a specific DRG category.
Filter openings by care setting before applying
Acute care, outpatient, and long-term care facilities expect different clinical documentation specialist skill sets. Tailor your resume to each setting by leading with the most relevant ICD coding experience or specialty service lines you've supported.
Apply early to roles that fit
Migrate Mate lists clinical documentation specialist openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Prepare to walk through a live query scenario
Many clinical documentation specialist interviews include a case review where you identify a documentation gap and draft a compliant physician query. Practice writing queries that are non-leading, specific to a DRG, and formatted to your target facility's preferred style.
Negotiate start date around credentialing timelines
If you're pursuing a CDIP or CCDS exam before your start date, disclose the timing upfront during offer discussions. Most health systems can accommodate a few weeks, and being transparent avoids gaps in your licensure status at onboarding.
Clinical Documentation Specialist Jobs: Frequently Asked Questions
Which companies are hiring the most clinical documentation specialists?
The companies hiring the most clinical documentation specialists right now include UASI, Ascension, and FutureSight, with the largest share of openings in Florida, Texas, and California, based on current listings on Migrate Mate as of August 2026. Large academic medical centers and regional health systems consistently account for a significant portion of active openings.
How many clinical documentation specialist jobs are remote?
About 64% of clinical documentation specialist openings are fully remote or hybrid as of August 2026, reflecting a shift that accelerated after health systems invested in telehealth infrastructure. Remote roles are most common in outpatient CDI, audit, and query management positions, while inpatient concurrent review roles more frequently require on-site presence.
How do you become a clinical documentation specialist?
Start by building a foundation in clinical coding or nursing, as most employers require direct patient care or health information management experience. Earn a coding credential such as an RHIT or RHIA through an accredited health information program, then pursue a specialized CDI credential like the CDIP from AHIMA or CCDS from ACDIS. Hands-on experience reviewing inpatient records and drafting physician queries before you apply strengthens your candidacy significantly.
Can you get hired as a clinical documentation specialist with little experience?
Yes, entry-level clinical documentation specialist roles do exist, particularly at facilities with formal CDI training programs. Candidates with a background in inpatient coding, nursing, or respiratory therapy often move into CDI with less than a year of dedicated CDI experience. Completing a CDI boot camp or obtaining your CDIP or CCDS while in a related role signals commitment and helps bridge the experience gap for hiring managers.
What does the clinical documentation specialist interview process look like?
Most clinical documentation specialist interview processes include an initial phone screen with HR, followed by a technical interview with the CDI manager or director covering coding guidelines, DRG methodology, and query writing standards. Candidates are often given a case-based exercise where they review a sample medical record and identify documentation gaps. A final panel interview with compliance or revenue cycle leadership is common at larger health systems.
Where can I find and apply to clinical documentation specialist jobs?
You can find and apply to clinical documentation specialist jobs on Migrate Mate, which lists current openings from across the United States. Search the listings to find roles that match your experience, care setting preference, and location, then apply directly to each opening that fits.
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