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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Showing 5 of 56+ Clinical Documentation Specialist jobs
Location
Salisbury, MD
Facility
TidalHealth Corporate
Department
Health Information Management
Schedule - Shift - Hours
Full Time - Monday - Friday - 6:00 am to 2:30 pm
Req #:
36748
Salary
$75,670.40 - $121,076.80 / Annually
Why work at TidalHealth?
Join a triple 'A' rated team where clinical excellence meets a coastal lifestyle. At TidalHealth, you’ll be part of an award-winning network spanning Maryland and Delaware, recognized by the Leapfrog Hospital Safety Guide for our unwavering commitment to patient care. Whether your expertise lies in specialized clinical fields like neurosurgery, academic mentorship through our graduate medical programs, or the critical professional and support roles that keep our network thriving, we provide the tools and tuition assistance you need to excel.
Clinical Documentation Specialist Position Summary
The Clinical Documentation Integrity (CDI) Specialist ensures accurate and complete provider-based clinical documentation at TidalHealth. This position analyzes patients' clinical status, treatment plans, and medical history to identify documentation improvement opportunities. The role involves thorough chart reviews and collaboration with providers, nurses, consultants, and HIM coding staff to ensure proper reimbursement and accurate clinical data. CDI Specialists audit and monitor key quality indicators such as MHAC/PPCs, PSIs, HACs, and mortality reviews. The Specialist works closely with healthcare teams to ensure compliance with coding standards and regulatory requirements. The CDI Specialist also communicates with providers using verbal and electronic queries to clarify or improve documentation in line with AHIMA guidelines. The Specialist utilizes ICD-10 coding guidelines and applies the guidelines during documentation evaluations. The role includes developing tools and education plans to support accurate provider documentation. CDI Specialists help design workflows for documentation improvement and provide training for staff and new employees.
Education
Bachelor’s degree in nursing (BSN) is required, or relevant clinical CDI experience may be considered.
Required License and/or Certifications
- Licensed as a Registered Nurse (RN) in the state of residency
- Certified Clinical Document Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) is required.
- CCS, RHIT or RHIA is preferred.
Required experience:
- Minimum of one (1) year in inpatient coding and/or CDI experience
- Previous experience utilizing Microsoft Office products and EMR
Preferred Experience
- Experience in an acute care health facility
- Previous medical record coding/documentation auditing experience
- Experience with APR DRG & MS-DRG payment systems
- Experience with ICD10 coding methodology, coding guidelines and Clinical documentation integrity programs
- Previous experience with auditing quality measures – PSIs, HACs, Mortality, and MHAC/PPCs.
- Experience with EPIC and 3m 360/CDI Engage One
Clinical Documentation Specialist Work Schedule
- Primarily Day shift Monday – Friday.
- Hybrid- Remote position
- Evening and weekend work as needed.
Clinical Documentation Specialist Benefits
Benefits: We provide a robust benefits suite for our eligible team members (36+ hours for 12-hour shifts; 37.5+ hours for standard shifts):
- Health: Medical (including HSA), Dental, Vision, & Prescription
- Wealth: Matching 403(b), Healthcare FSAs, & Dependent Care FSAs
- Growth: $5,000 Tuition Assistance & Certification support
- Balance: Generous PTO and Holidays, Onsite Child Care, Pet Insurance
- Income Protection & Leave: Employer-Paid Short-Term Disability, Paid Leave Program, & Long-Term Disability (LTD for FT)
- Life & Security: Employer-paid Life and additional voluntary benefits such as Accident, Critical Care, additional Life, and more
Location
Salisbury, MD
Facility
TidalHealth Corporate
Department
Health Information Management
Schedule - Shift - Hours
Full Time - Monday - Friday - 6:00 am to 2:30 pm
Req #:
36748
Salary
$75,670.40 - $121,076.80 / Annually
Why work at TidalHealth?
Join a triple 'A' rated team where clinical excellence meets a coastal lifestyle. At TidalHealth, you’ll be part of an award-winning network spanning Maryland and Delaware, recognized by the Leapfrog Hospital Safety Guide for our unwavering commitment to patient care. Whether your expertise lies in specialized clinical fields like neurosurgery, academic mentorship through our graduate medical programs, or the critical professional and support roles that keep our network thriving, we provide the tools and tuition assistance you need to excel.
Clinical Documentation Specialist Position Summary
The Clinical Documentation Integrity (CDI) Specialist ensures accurate and complete provider-based clinical documentation at TidalHealth. This position analyzes patients' clinical status, treatment plans, and medical history to identify documentation improvement opportunities. The role involves thorough chart reviews and collaboration with providers, nurses, consultants, and HIM coding staff to ensure proper reimbursement and accurate clinical data. CDI Specialists audit and monitor key quality indicators such as MHAC/PPCs, PSIs, HACs, and mortality reviews. The Specialist works closely with healthcare teams to ensure compliance with coding standards and regulatory requirements. The CDI Specialist also communicates with providers using verbal and electronic queries to clarify or improve documentation in line with AHIMA guidelines. The Specialist utilizes ICD-10 coding guidelines and applies the guidelines during documentation evaluations. The role includes developing tools and education plans to support accurate provider documentation. CDI Specialists help design workflows for documentation improvement and provide training for staff and new employees.
Education
Bachelor’s degree in nursing (BSN) is required, or relevant clinical CDI experience may be considered.
Required License and/or Certifications
- Licensed as a Registered Nurse (RN) in the state of residency
- Certified Clinical Document Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) is required.
- CCS, RHIT or RHIA is preferred.
Required experience:
- Minimum of one (1) year in inpatient coding and/or CDI experience
- Previous experience utilizing Microsoft Office products and EMR
Preferred Experience
- Experience in an acute care health facility
- Previous medical record coding/documentation auditing experience
- Experience with APR DRG & MS-DRG payment systems
- Experience with ICD10 coding methodology, coding guidelines and Clinical documentation integrity programs
- Previous experience with auditing quality measures – PSIs, HACs, Mortality, and MHAC/PPCs.
- Experience with EPIC and 3m 360/CDI Engage One
Clinical Documentation Specialist Work Schedule
- Primarily Day shift Monday – Friday.
- Hybrid- Remote position
- Evening and weekend work as needed.
Clinical Documentation Specialist Benefits
Benefits: We provide a robust benefits suite for our eligible team members (36+ hours for 12-hour shifts; 37.5+ hours for standard shifts):
- Health: Medical (including HSA), Dental, Vision, & Prescription
- Wealth: Matching 403(b), Healthcare FSAs, & Dependent Care FSAs
- Growth: $5,000 Tuition Assistance & Certification support
- Balance: Generous PTO and Holidays, Onsite Child Care, Pet Insurance
- Income Protection & Leave: Employer-Paid Short-Term Disability, Paid Leave Program, & Long-Term Disability (LTD for FT)
- Life & Security: Employer-paid Life and additional voluntary benefits such as Accident, Critical Care, additional Life, and more
See All 56+ Clinical Documentation Specialist Jobs
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Find JobsClinical Documentation Specialist Job Market
A snapshot from current openings nationwide, updated as new roles post.
Who's Hiring
- Beth Israel Lahey Health7
- Trinity Health5
- Hartford HealthCare4
- Optum2
- TidalHealth2
Top Industries Hiring
- Healthcare & Medical Services43
- Biotechnology & Pharmaceuticals5
- Education4
- Insurance4
- Science & Research3
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 Beth Israel Lahey Health, Trinity Health, and Hartford HealthCare, with the largest share of openings in Massachusetts, Connecticut, and New York, based on current listings on Migrate Mate as of June 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 59% of clinical documentation specialist openings are fully remote or hybrid as of June 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.
See All 56+ Clinical Documentation Specialist Jobs
Jump back to the full list of openings and apply to any clinical documentation specialist role that fits.
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