Entry Level Clinical Documentation Specialist Jobs
New grad clinical documentation specialist jobs welcome recent graduates and entry level candidates with zero to two years of experience, where a strong internship background or portfolio of health record coursework can matter more than a long resume. Most openings are Healthcare & Medical Services, Biotechnology & Pharmaceuticals, and Technology & Software roles with employers like Beth Israel Lahey Health, Optum, and Medpace hiring at this level now.
Find JobsOverview
Showing 3 of 20+ Entry Level Clinical Documentation Specialist jobs
Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.
The Clinical Document Integrity Specialist - (CDIS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal of the CDS oversight and practice is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.
This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. The CDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals, and core values of Optum 360.
In this position the CDS will utilizing the Optum™ CDI 3D technology that is assisting hospitals to improve data quality to accurately reflect the quality of care provided and ensure revenue integrity.
Our three-dimensional approach to CDI technology, paired with best-practice adoption methodology and change management support, is helping hospitals make a real impact on CDI efficiency and effectiveness.
- Increase in identification of cases with CDI opportunities, with automated review of 100% of records
- Improved tracking, transparency and reporting related to CDI impact, revenue capture, trending, and compliance
- Easing the transition to ICD-10 by improving the specificity and completeness of clinical documentation, resulting in more accurate coding
This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.
***Work Location: hybrid - St. Rose Dominican Hospital, Las Vegas, NV***
Weekend Coverage: Friday - Tuesday
If you are located in Las Vegas, NV, you will have the flexibility to work remotely*, as well as work in the office as you take on some tough challenges. This position follows a hybrid schedule with three in-office days per week.
Primary Responsibilities:
- Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
- Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
- Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rationale for the recommendations
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
- Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
- Provides face-to-face educational opportunities with physicians on a regular basis
- Provides complete follow through on all requests for clarification or recommendations for improvement
- Leads the development and execution of physician education strategies resulting in improved clinical documentation
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
- Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activity
- Utilizes only the Optum360 approved clarification forms
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
- Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
- Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- 2+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
- Experience communicating & working closely with Physicians
- Proficiency using a PC in a Google environment and Electronic Medical Records
- Willing to work weekend coverage, Friday - Tuesday - 8 hours days
- Willing to be onsite at St. Rose Dominican Hospital, Las Vegas on a hybrid schedule
Preferred Qualifications:
- BSN degree if a RN
- CCDS, CDIP or CCS certification
- Experience in Clinical Documentation Improvement
- CAC experience (Computer Assistant Coding)
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.
The Clinical Document Integrity Specialist - (CDIS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the concurrent review of the clinical documentation in the inpatient medical record of Optum 360 clients' patients. The goal of the CDS oversight and practice is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.
This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decisions, and diagnoses for the patient. The CDS utilizes clinical expertise and clinical documentation improvement practices as well as facility specific tools for best practice and compliance with the mission/philosophy, standards, goals, and core values of Optum 360.
In this position the CDS will utilizing the Optum™ CDI 3D technology that is assisting hospitals to improve data quality to accurately reflect the quality of care provided and ensure revenue integrity.
Our three-dimensional approach to CDI technology, paired with best-practice adoption methodology and change management support, is helping hospitals make a real impact on CDI efficiency and effectiveness.
- Increase in identification of cases with CDI opportunities, with automated review of 100% of records
- Improved tracking, transparency and reporting related to CDI impact, revenue capture, trending, and compliance
- Easing the transition to ICD-10 by improving the specificity and completeness of clinical documentation, resulting in more accurate coding
This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care.
***Work Location: hybrid - St. Rose Dominican Hospital, Las Vegas, NV***
Weekend Coverage: Friday - Tuesday
If you are located in Las Vegas, NV, you will have the flexibility to work remotely*, as well as work in the office as you take on some tough challenges. This position follows a hybrid schedule with three in-office days per week.
Primary Responsibilities:
- Provides expert level review of inpatient clinical records within 24-48 hours of admit; identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure the documentation accurately reflects the severity of the condition and acuity of care provided
- Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity
- Provides expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating recommendations for improvement, and the rationale for the recommendations
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality
- Performs regular rounding with unit-based physicians and provides Working DRG lists to Care Coordination
- Provides face-to-face educational opportunities with physicians on a regular basis
- Provides complete follow through on all requests for clarification or recommendations for improvement
- Leads the development and execution of physician education strategies resulting in improved clinical documentation
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and successes
- Ensures effective utilization of Optum® CDI 3D Technology to document all clarification activity
- Utilizes only the Optum360 approved clarification forms
- Proactively develops a reciprocal relationship with the HIM Coding Professionals
- Coordinates and conducts regular meeting with HIM Coding Professionals to reconsolidate DRGs, monitor retrospective query rates and discuss questions related to Coding and CDI
- Engages and consults with Physician Advisor / VPMA when needed, per the escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process
- Actively engages with Care Coordination and the Quality Management teams to continually evaluate and spearhead clinical documentation improvement opportunities
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:
- 2+ years acute care hospital clinical RN experience OR Medical Graduate with CDI experience and CDI certification (CCDS, CDIP)
- Experience communicating & working closely with Physicians
- Proficiency using a PC in a Google environment and Electronic Medical Records
- Willing to work weekend coverage, Friday - Tuesday - 8 hours days
- Willing to be onsite at St. Rose Dominican Hospital, Las Vegas on a hybrid schedule
Preferred Qualifications:
- BSN degree if a RN
- CCDS, CDIP or CCS certification
- Experience in Clinical Documentation Improvement
- CAC experience (Computer Assistant Coding)
All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $72,800 - $130,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.
UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.
UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.
See All 20 Entry Level Clinical Documentation Specialist Jobs
Find roles that match your experience and apply in just a few clicks.
Find JobsEntry Level Clinical Documentation Specialist Job Market
Who's Hiring
Top Industries Hiring
- Healthcare & Medical Services16
- Biotechnology & Pharmaceuticals3
- Technology & Software1
- Government & Public Sector1
Entry Level Clinical Documentation Specialist Jobs: Frequently Asked Questions
How do I get an entry level clinical documentation specialist job?
Employers hiring at this level look for familiarity with ICD-10 coding systems, electronic health records platforms, and medical terminology, which you can build through a health information management program or a clinical coding certificate. Candidates who can show accuracy and attention to detail in coursework or internship work stand out. Applying to hospital systems, outpatient clinics, and health IT vendors that explicitly list zero to two years of experience gives you the strongest starting point.
Which companies hire entry level clinical documentation specialists?
Companies hiring entry level clinical documentation specialists right now include Beth Israel Lahey Health, Optum, and Medpace, based on current listings on Migrate Mate as of August 2026. Hiring at this level tends to come from large hospital networks, outpatient care organizations, and health information management firms that have the training infrastructure to bring on candidates early in their careers.
Are there remote entry level clinical documentation specialist jobs?
Yes, though availability varies by employer and role type. About 42% of entry level clinical documentation specialist openings are remote or hybrid as of August 2026, making this one of the more flexible healthcare-adjacent fields for new candidates. Remote roles typically require a reliable home setup and comfort working independently within an electronic health records system.
Are these new grad clinical documentation specialist jobs?
Yes, this page includes new grad, recent graduate, and junior clinical documentation specialist roles. A posting is typically new-grad friendly when it welcomes zero to two years of experience, accepts internship or practicum work in place of full-time history, or notes that a relevant degree or certification is sufficient to apply. Looking for those signals in the job description is the quickest way to find roles suited to someone starting out.
Which industries hire the most entry level clinical documentation specialists?
Entry Level clinical documentation specialist roles concentrate in Healthcare & Medical Services, Biotechnology & Pharmaceuticals, and Technology & Software, based on current listings on Migrate Mate as of August 2026. These sectors drive entry level hiring because they process high volumes of patient records and rely on a steady pipeline of trained specialists to maintain coding accuracy and regulatory compliance.