Mid Level Clinical Documentation Specialist Jobs
Mid level clinical documentation specialist jobs go to professionals ready to own query workflows, mentor junior reviewers, and drive documentation accuracy decisions with limited oversight. Roles cover 33% remote or hybrid settings across Healthcare & Medical Services, Education, and Insurance, with employers like Optum, Jobot, and R1 RCM hiring at this level now.
Find JobsOverview
Open roles31
Top stateTexas
Top employerOptum
Top cityDallas, TX
Work type67% On-site
Top industryHealthcare
Showing 5 of 31+ Mid Level Clinical Documentation Specialist jobs
Clinical Documentation Specialist
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Added 3d ago
The University of Texas Rio Grande Valley
Clinical Documentation Specialist
Harlingen, Texas
Added 3d ago
Clinical Documentation Specialist
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Added 4d ago
Saint Alphonsus
Clinical Documentation Specialist
Boise, Idaho
Added 4d ago
Clinical Documentation Integrity (CDI) Analyst (Remote)
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Added 5d ago
University Hospitals
Clinical Documentation Integrity (CDI) Analyst (Remote)
Shaker Heights, Ohio
Added 5d ago
Clinical Documentation Improvement Specialist
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Added 6d ago
Community Health System
Clinical Documentation Improvement Specialist
Fresno, California
Added 6d ago
Clinical Documentation Improvement Specialist - Santa Maria, CA
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Added 1w ago
Optum
Clinical Documentation Improvement Specialist - Santa Maria, CA
Santa Maria, California
Added 1w ago
Added 3d ago
Clinical Documentation Specialist
The University of Texas Rio Grande Valley·Harlingen, Texas
Job functions:
5+ yrs exp.
Bachelor's degree
Full Time
1,001-5,000 employees
Job Description
Number of Vacancies
1
Location
Harlingen, Texas
Department
School of Medicine/ Revenue Cycle
FTE
1.0
FLSA
Exempt
Scope of Job
To promote appropriate clinical documentation through collaboration with the School of Medicine clinical staff by reviewing patient documents, assessing for accuracy and educating the patient care team to ensure guidelines are met and appropriate process is followed.
Description of Duties
- Obtains and promotes appropriate clinical documentation through interaction with clinical staff and physicians to ensure documentation is complete, accurate and reflects the level of service rendered to patients.
- Conducts complex reviews of physician/provider billing compliance activities in accordance with applicable laws, regulations, rules or policies.
- Performs prospective and retrospective audits of documentation to confirm compliance with documentation and billing rules and government regulations. Provides feedback and education related to audit results.
- Reviews documentation by physicians and clinical staff as well as lab results, diagnostic information and treatment plans to assure accuracy.
- Reviews files to identify documentation gaps and requests clarification from physicians and other caregivers of unclear diagnoses, patient complications, procedures and clinical documentation.
- Works closely with Revenue Cycle billing/collection staff to ensure accurate physician reimbursement is achieved and claims denials are reduced by ensuring documentation integrity.
- Educates all members of the patient care team on documentation guidelines on an ongoing basis.
- Develops and presents on-going documentation education for staff including coders, physicians, residents, clinical staff, and allied health professionals.
- Prepares reports, provides supporting evidence and makes recommendations regarding identified documentation and coding deficiencies or gaps. Identifies trends and provides feedback to medical staff, coders, and management.
- Acts as a knowledge expert to service providers and coders through familiarity with coding conventions.
- Works closely with Revenue Cycle coding staff on Clinical Documentation Improvement (CDI) activities, processes, and procedures.
- Provides education for medical student and resident orientation/development and other times as necessary.
- Presents recommendations for quality management and processes improvement opportunities regarding workflow and or policies and procedures as necessary.
- Maintains a thorough understanding of CPT, ICD-10 CM, and HCPCS coding principles, and keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
- Maintains positive and open communication with physicians, management and Revenue Cycle team.
- Adheres to internal controls and reporting structure.
- Performs other duties as assigned.
Supervision Received
General supervision from assigned supervisor.
Supervision Given
Direct supervision of assigned staff.
Required Education
Bachelor’s degree in Nursing, Health Information Management or related field from an accredited University.
Preferred Education
None.
Licenses/Certifications
Certified Professional Coder (CPC) from American Academy Professional Coders (AAPC), or Certified Coding Specialist – P (CCS – P) from the American Health Information Management Association (AHIMA), or Certified Professional Medical Auditor (CPMA), or,
At time of hire, Registered Health Information Technician (RHIT) from the American Health Information Management Association (AHIMA), or Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA), or Current State of Texas Professional Nursing License (RN), and must obtain one of the coding certifications stated above (CPC, CCS-P, CPMA) within 6 months of employment.
Preferred: Certified Clinical Documentation Improvement Practitioner (CDI) from the American Health Information Management Association (AHIMA).
At time of hire, Registered Health Information Technician (RHIT) from the American Health Information Management Association (AHIMA), or Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA), or Current State of Texas Professional Nursing License (RN), and must obtain one of the coding certifications stated above (CPC, CCS-P, CPMA) within 6 months of employment.
Preferred: Certified Clinical Documentation Improvement Practitioner (CDI) from the American Health Information Management Association (AHIMA).
Required Experience
Five (5) years of clinical coding and/or nursing experience in an ambulatory setting or in an acute care facility. May substitute required degree with additional years of experience on a one-to-one basis.
Preferred Experience
Five years of clinical documentation experience in an acute care facility.
Equipment
Use of standard office equipment.
Working Conditions
Needs to be able to successfully perform all required duties. Office and patient care environment; some travel and weekend work is required. UTRGV is a distributed institution, which requires presence at multiple locations throughout the Rio Grande Valley.
Other
Has a good understanding of all clinical information systems and data flow across the continuum. Ability to communicate effectively, written and verbal. Tact, diplomacy, discretion, and confidentiality of medical information required in all matters.
Physical Capabilities
N/A
Employment Category
Full-Time
Minimum Salary
Commensurate with Experience
Posted Salary
Commensurate with Experience
Position Available Date
10/05/2025
Grant Funded Position
No
If Yes, Provide Grant Expiration Date
Posting Detail Information
EEO Statement
It is the policy of The University of Texas Rio Grande Valley to promote and ensure equal employment opportunities for all individuals without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or protected veteran status. In accordance with the requirements of Title VII of the Civil Rights Act of 1964, the Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, as amended, our University is committed to comply with all government requirements and ensures non-discrimination in its education programs and activities, including employment. We encourage women, minorities and differently abled persons to apply for employment positions of interest.
Special Instructions to Applicants
Dear Applicant, Human Resources will not be held responsible for redacting any confidential information from the documents you attach with your application. The confidential information includes the following: *Date of Birth *Gender *Ethnicity/Race Please make sure that you omit this information prior to submission. We are advising that Human Resources will be forwarding your application to the department as per your submission. The University of Texas Rio Grande Valley reserves the right to discontinue accepting applications prior to the stated close date of this position, after meeting the posting requirement of three (3) calendar days. If you have any questions, please visit our Careers site at https://careers.utrgv.edu for detailed contact information.
Additional Information
UTRGV is a distributed location institution and working location is subject to change based on need.
All UTRGV employees are required to have a criminal background check (CBC). Incomplete applications will not be considered.
Substitutions to the above requirements must have prior approval from the VP of Human Resources.
All UTRGV employees are required to have a criminal background check (CBC). Incomplete applications will not be considered.
Substitutions to the above requirements must have prior approval from the VP of Human Resources.
The University of Texas Rio Grande Valley
Clinical Documentation Specialist
Harlingen, Texas
Added 3d ago1,001-5,000 employees
Job functions:
5+ yrs exp.
Bachelor's degree
Full Time
Job Description
Number of Vacancies
1
Location
Harlingen, Texas
Department
School of Medicine/ Revenue Cycle
FTE
1.0
FLSA
Exempt
Scope of Job
To promote appropriate clinical documentation through collaboration with the School of Medicine clinical staff by reviewing patient documents, assessing for accuracy and educating the patient care team to ensure guidelines are met and appropriate process is followed.
Description of Duties
- Obtains and promotes appropriate clinical documentation through interaction with clinical staff and physicians to ensure documentation is complete, accurate and reflects the level of service rendered to patients.
- Conducts complex reviews of physician/provider billing compliance activities in accordance with applicable laws, regulations, rules or policies.
- Performs prospective and retrospective audits of documentation to confirm compliance with documentation and billing rules and government regulations. Provides feedback and education related to audit results.
- Reviews documentation by physicians and clinical staff as well as lab results, diagnostic information and treatment plans to assure accuracy.
- Reviews files to identify documentation gaps and requests clarification from physicians and other caregivers of unclear diagnoses, patient complications, procedures and clinical documentation.
- Works closely with Revenue Cycle billing/collection staff to ensure accurate physician reimbursement is achieved and claims denials are reduced by ensuring documentation integrity.
- Educates all members of the patient care team on documentation guidelines on an ongoing basis.
- Develops and presents on-going documentation education for staff including coders, physicians, residents, clinical staff, and allied health professionals.
- Prepares reports, provides supporting evidence and makes recommendations regarding identified documentation and coding deficiencies or gaps. Identifies trends and provides feedback to medical staff, coders, and management.
- Acts as a knowledge expert to service providers and coders through familiarity with coding conventions.
- Works closely with Revenue Cycle coding staff on Clinical Documentation Improvement (CDI) activities, processes, and procedures.
- Provides education for medical student and resident orientation/development and other times as necessary.
- Presents recommendations for quality management and processes improvement opportunities regarding workflow and or policies and procedures as necessary.
- Maintains a thorough understanding of CPT, ICD-10 CM, and HCPCS coding principles, and keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
- Maintains positive and open communication with physicians, management and Revenue Cycle team.
- Adheres to internal controls and reporting structure.
- Performs other duties as assigned.
Supervision Received
General supervision from assigned supervisor.
Supervision Given
Direct supervision of assigned staff.
Required Education
Bachelor’s degree in Nursing, Health Information Management or related field from an accredited University.
Preferred Education
None.
Licenses/Certifications
Certified Professional Coder (CPC) from American Academy Professional Coders (AAPC), or Certified Coding Specialist – P (CCS – P) from the American Health Information Management Association (AHIMA), or Certified Professional Medical Auditor (CPMA), or,
At time of hire, Registered Health Information Technician (RHIT) from the American Health Information Management Association (AHIMA), or Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA), or Current State of Texas Professional Nursing License (RN), and must obtain one of the coding certifications stated above (CPC, CCS-P, CPMA) within 6 months of employment.
Preferred: Certified Clinical Documentation Improvement Practitioner (CDI) from the American Health Information Management Association (AHIMA).
At time of hire, Registered Health Information Technician (RHIT) from the American Health Information Management Association (AHIMA), or Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA), or Current State of Texas Professional Nursing License (RN), and must obtain one of the coding certifications stated above (CPC, CCS-P, CPMA) within 6 months of employment.
Preferred: Certified Clinical Documentation Improvement Practitioner (CDI) from the American Health Information Management Association (AHIMA).
Required Experience
Five (5) years of clinical coding and/or nursing experience in an ambulatory setting or in an acute care facility. May substitute required degree with additional years of experience on a one-to-one basis.
Preferred Experience
Five years of clinical documentation experience in an acute care facility.
Equipment
Use of standard office equipment.
Working Conditions
Needs to be able to successfully perform all required duties. Office and patient care environment; some travel and weekend work is required. UTRGV is a distributed institution, which requires presence at multiple locations throughout the Rio Grande Valley.
Other
Has a good understanding of all clinical information systems and data flow across the continuum. Ability to communicate effectively, written and verbal. Tact, diplomacy, discretion, and confidentiality of medical information required in all matters.
Physical Capabilities
N/A
Employment Category
Full-Time
Minimum Salary
Commensurate with Experience
Posted Salary
Commensurate with Experience
Position Available Date
10/05/2025
Grant Funded Position
No
If Yes, Provide Grant Expiration Date
Posting Detail Information
EEO Statement
It is the policy of The University of Texas Rio Grande Valley to promote and ensure equal employment opportunities for all individuals without regard to race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity or expression, genetic information or protected veteran status. In accordance with the requirements of Title VII of the Civil Rights Act of 1964, the Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, as amended, our University is committed to comply with all government requirements and ensures non-discrimination in its education programs and activities, including employment. We encourage women, minorities and differently abled persons to apply for employment positions of interest.
Special Instructions to Applicants
Dear Applicant, Human Resources will not be held responsible for redacting any confidential information from the documents you attach with your application. The confidential information includes the following: *Date of Birth *Gender *Ethnicity/Race Please make sure that you omit this information prior to submission. We are advising that Human Resources will be forwarding your application to the department as per your submission. The University of Texas Rio Grande Valley reserves the right to discontinue accepting applications prior to the stated close date of this position, after meeting the posting requirement of three (3) calendar days. If you have any questions, please visit our Careers site at https://careers.utrgv.edu for detailed contact information.
Additional Information
UTRGV is a distributed location institution and working location is subject to change based on need.
All UTRGV employees are required to have a criminal background check (CBC). Incomplete applications will not be considered.
Substitutions to the above requirements must have prior approval from the VP of Human Resources.
All UTRGV employees are required to have a criminal background check (CBC). Incomplete applications will not be considered.
Substitutions to the above requirements must have prior approval from the VP of Human Resources.
See All 31 Mid Level Clinical Documentation Specialist Jobs
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Find JobsMid Level Clinical Documentation Specialist Job Market
Who's Hiring
Top Industries Hiring
- Healthcare & Medical Services21
- Education5
- Insurance4
- Science & Research1
- Accounting & Auditing1
Mid Level Clinical Documentation Specialist Jobs: Frequently Asked Questions
How do I get a mid level clinical documentation specialist job?
Lead with ownership, not just participation. Highlight cases where you resolved complex query discrepancies, improved documentation quality metrics, or guided less experienced staff through clinical coding challenges. Employers at this level want evidence that you can work independently, catch issues before they escalate, and contribute to process improvements. Tailor your resume to show measurable impact, not just task completion.
Which companies hire mid level clinical documentation specialists?
Companies hiring mid level clinical documentation specialists right now include Optum, Jobot, and R1 RCM, based on current listings on Migrate Mate as of September 2026. Health systems, academic medical centers, revenue cycle management firms, and large physician group practices are the most active employers at this experience level.
Are there remote mid level clinical documentation specialist jobs?
Yes, remote and hybrid options are common at this level. About 33% of mid level clinical documentation specialist openings are remote or hybrid as of September 2026, reflecting how widespread electronic health record platforms have made remote query work and record review fully practical for experienced specialists.
How do I move up to a mid level clinical documentation specialist role?
Growth from entry level into mid level comes from building depth in clinical query management, expanding your knowledge of coding guidelines such as ICD-10-CM and MS-DRG, and taking on more complex case types over time. Earning credentials like the CCDS or CDIP, demonstrating consistent accuracy rates, and volunteering for quality audits or onboarding new staff signals readiness for mid level responsibility.
Which industries hire the most mid level clinical documentation specialists?
Mid Level clinical documentation specialist roles concentrate in Healthcare & Medical Services, Education, and Insurance, based on current listings on Migrate Mate as of September 2026. These sectors drive hiring at this level because their reimbursement complexity and compliance requirements depend on experienced specialists who can work with minimal supervision and maintain documentation integrity across high patient volumes.