Entry Level Documentation Specialist Jobs
New grad documentation specialist jobs welcome recent graduates and entry level candidates with zero to two years of experience, where a strong portfolio or internship work can matter more than a long resume. Most openings mix on-site and remote roles across Healthcare & Medical Services, Insurance, and Science & Research, with employers like Beth Israel Lahey Health, Trinity Health, and Northwell Health hiring at this level now.
Find JobsOverview
Open roles32
Top stateMassachusetts
Top employerBeth Israel Lahey Health
Top cityBoston, MA
Work type67% Remote
Top industryHealthcare
Showing 5 of 32+ Entry Level Documentation Specialist jobs
Clinical Documentation Integrity Specialist
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Added 2d ago
Fairview Health Services
Clinical Documentation Integrity Specialist
Saint Paul, Minnesota
Added 2d ago
Clinical Documentation Specialist
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Added 1w ago
Northwell Health
Clinical Documentation Specialist
Lake Success, New York
Added 1w ago
Clinical Documentation Integrity Specialist
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Added 2w ago
Memorial Healthcare System
Clinical Documentation Integrity Specialist
Miramar, Florida
Added 2w ago
Clinical Documentation Specialist
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Added 2w ago
Family Health Center
Clinical Documentation Specialist
Worcester, Massachusetts
Added 2w ago
Clinical Study Documentation Specialist
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Added 2w ago
Caris Life Sciences
Clinical Study Documentation Specialist
Phoenix, Arizona
Added 2w ago
Added 2d ago
Clinical Documentation Integrity Specialist
Fairview Health Services·Saint Paul, Minnesota
Job functions:
$82k - $115k/yr
2+ yrs exp.
Remote (US)
Associate's degree in health information management
Full Time
10,000+ employees
Job Description
Responsibilities/Job Description:
Clinical Documentation Integrity (CDI) Specialist – Remote
Join Fairview as a Clinical Documentation Integrity Specialist and play a key role in ensuring accurate, complete, and compliant inpatient medical record documentation. In this fully remote position, you'll collaborate with physicians, coders, and clinical teams to review patient records, identify documentation improvement opportunities, support accurate DRG assignment, and enhance quality outcomes, regulatory compliance, and reimbursement.
Why Fairview?
Responsibilities
Required Qualifications
Qualifications:
Clinical Documentation Integrity (CDI) Specialist – Remote
Join Fairview as a Clinical Documentation Integrity Specialist and play a key role in ensuring accurate, complete, and compliant inpatient medical record documentation. In this fully remote position, you'll collaborate with physicians, coders, and clinical teams to review patient records, identify documentation improvement opportunities, support accurate DRG assignment, and enhance quality outcomes, regulatory compliance, and reimbursement.
This role is ideal for an experienced RN, RHIA, or RHIT professional with a strong understanding of clinical documentation, coding, and inpatient care. You'll use your analytical skills and clinical expertise to drive documentation excellence while educating providers and contributing to continuous improvement initiatives.
Why Fairview?
- Fully remote position
- Salaried role with comprehensive benefits
- As needed weekends
- Collaborative, mission-driven healthcare environment
- Opportunity to influence patient care quality and organizational outcomes
If you're passionate about clinical documentation, healthcare quality, and provider collaboration, we'd love to hear from you.
Responsibilities
- Completes a concurrent review of the medical record for assigned patients in the required timeframe.
- Performs daily case reviews and identifies diagnoses and procedures in order to assign in accurate working DRG. Performs follow-up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. Confers with coders to ensure appropriate final DRG and completeness of supporting documentation.
- Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. Confers with nursing, case management, utilization review and other clinical caregivers to explain the importance of clear and concise documentation.
- Collects and analyzes data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
- Organization Expectations, as applicable:
- Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
- Partners with patient care giver in care/decision making.
- Communicates in a respective manner.
- Ensures a safe, secure environment.
- Individualizes plan of care to meet patient needs.
- Modifies clinical interventions based on population served.
- Provides patient education based on as assessment of learning needs of patient/care giver.
- Fulfills all organizational requirements
- Completes all required learning relevant to the role
- Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures and standards.
- Fosters a culture of improvement, efficiency and innovative thinking.
- Performs other duties as assigned
Required Qualifications
- Associates Degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience
- 2 years Acute/Inpatient experience as an RN or 5 years inpatient coding experience
- Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations
- Knowledge of current coding and DRG classification systems
- Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results
- Knowledge of ICD-10-CM and DRG classification systems
- Knowledge of physician and nursing unit practices
- Excellent interpersonal, critical thinking and conflict management skills
- Computer and data analysis skills
- Excellent verbal and written communication and presentation skills
- Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions
- Attention to detail: Achieve thoroughness and accuracy when accomplishing a task
- Critical Thinking: Gathers and integrates critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions
- Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust
- Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations
- Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing
- Registered Nurse of MN Upon Hire or
- current Registered Health Information Administrator (RHIA) MN Board of Nursing or American Health Information Management Association Upon Hire or
- Registered Health Information Tech (RHIT) MN Board of Nursing or American Health Information Management Association Upon Hire
Preferred Qualifications
- Bachelors Degree in Nursing for candidate’s with nursing experience
- 5 years acute care nursing or
- 5 years inpatient coding experience
- Certified Clinical Documentation Specialist (CCDS) for candidate’s with HIM experience American Health Information Management Association Upon Hire
Qualifications:
$81,702.40- $115,336.00 Annual
Fairview Health Services
Clinical Documentation Integrity Specialist
Saint Paul, Minnesota
Added 2d ago10,000+ employees
Job functions:
$82k - $115k/yr
2+ yrs exp.
Remote (US)
Associate's degree in health information management
Full Time
Job Description
Responsibilities/Job Description:
Clinical Documentation Integrity (CDI) Specialist – Remote
Join Fairview as a Clinical Documentation Integrity Specialist and play a key role in ensuring accurate, complete, and compliant inpatient medical record documentation. In this fully remote position, you'll collaborate with physicians, coders, and clinical teams to review patient records, identify documentation improvement opportunities, support accurate DRG assignment, and enhance quality outcomes, regulatory compliance, and reimbursement.
Why Fairview?
Responsibilities
Required Qualifications
Qualifications:
Clinical Documentation Integrity (CDI) Specialist – Remote
Join Fairview as a Clinical Documentation Integrity Specialist and play a key role in ensuring accurate, complete, and compliant inpatient medical record documentation. In this fully remote position, you'll collaborate with physicians, coders, and clinical teams to review patient records, identify documentation improvement opportunities, support accurate DRG assignment, and enhance quality outcomes, regulatory compliance, and reimbursement.
This role is ideal for an experienced RN, RHIA, or RHIT professional with a strong understanding of clinical documentation, coding, and inpatient care. You'll use your analytical skills and clinical expertise to drive documentation excellence while educating providers and contributing to continuous improvement initiatives.
Why Fairview?
- Fully remote position
- Salaried role with comprehensive benefits
- As needed weekends
- Collaborative, mission-driven healthcare environment
- Opportunity to influence patient care quality and organizational outcomes
If you're passionate about clinical documentation, healthcare quality, and provider collaboration, we'd love to hear from you.
Responsibilities
- Completes a concurrent review of the medical record for assigned patients in the required timeframe.
- Performs daily case reviews and identifies diagnoses and procedures in order to assign in accurate working DRG. Performs follow-up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. Confers with coders to ensure appropriate final DRG and completeness of supporting documentation.
- Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. Confers with nursing, case management, utilization review and other clinical caregivers to explain the importance of clear and concise documentation.
- Collects and analyzes data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
- Organization Expectations, as applicable:
- Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
- Partners with patient care giver in care/decision making.
- Communicates in a respective manner.
- Ensures a safe, secure environment.
- Individualizes plan of care to meet patient needs.
- Modifies clinical interventions based on population served.
- Provides patient education based on as assessment of learning needs of patient/care giver.
- Fulfills all organizational requirements
- Completes all required learning relevant to the role
- Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures and standards.
- Fosters a culture of improvement, efficiency and innovative thinking.
- Performs other duties as assigned
Required Qualifications
- Associates Degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience
- 2 years Acute/Inpatient experience as an RN or 5 years inpatient coding experience
- Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations
- Knowledge of current coding and DRG classification systems
- Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results
- Knowledge of ICD-10-CM and DRG classification systems
- Knowledge of physician and nursing unit practices
- Excellent interpersonal, critical thinking and conflict management skills
- Computer and data analysis skills
- Excellent verbal and written communication and presentation skills
- Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions
- Attention to detail: Achieve thoroughness and accuracy when accomplishing a task
- Critical Thinking: Gathers and integrates critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions
- Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust
- Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations
- Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing
- Registered Nurse of MN Upon Hire or
- current Registered Health Information Administrator (RHIA) MN Board of Nursing or American Health Information Management Association Upon Hire or
- Registered Health Information Tech (RHIT) MN Board of Nursing or American Health Information Management Association Upon Hire
Preferred Qualifications
- Bachelors Degree in Nursing for candidate’s with nursing experience
- 5 years acute care nursing or
- 5 years inpatient coding experience
- Certified Clinical Documentation Specialist (CCDS) for candidate’s with HIM experience American Health Information Management Association Upon Hire
Qualifications:
$81,702.40- $115,336.00 Annual
See All 32 Entry Level Documentation Specialist Jobs
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Find JobsEntry Level Documentation Specialist Job Market
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Top Industries Hiring
- Healthcare & Medical Services22
- Insurance2
- Science & Research2
- Biotechnology & Pharmaceuticals2
- Manufacturing1
Entry Level Documentation Specialist Jobs: Frequently Asked Questions
How do I get an entry level documentation specialist job?
Focus on building a portfolio that shows you can write clear, organized technical or procedural content. Employers at this level look for familiarity with tools like Microsoft Word, Google Docs, or basic content management systems, along with attention to detail. Internship experience, coursework in technical writing, or self-published samples all give you a concrete edge over candidates who rely on a degree alone.
Which companies hire entry level documentation specialists?
Companies hiring entry level documentation specialists right now include Beth Israel Lahey Health, Trinity Health, and Northwell Health, based on current listings on Migrate Mate as of July 2026. At this level, you'll find openings across large enterprises, government contractors, healthcare organizations, and growing technology companies, many of which actively recruit candidates with little formal experience but a clear aptitude for structured writing.
Are there remote entry level documentation specialist jobs?
Yes, and the share is meaningful. About 73% of entry level documentation specialist openings are remote or hybrid as of July 2026, reflecting how documentation work translates well to distributed teams. Many employers in technology, healthcare, and professional services post remote-eligible roles specifically for early-career candidates who can demonstrate strong written communication without requiring on-site supervision.
Are these new grad documentation specialist jobs?
Yes. These listings include new grad, recent graduate, and junior roles that explicitly welcome candidates with zero to two years of experience. A new grad friendly posting typically accepts internship work, academic projects, or a writing portfolio in place of full-time professional history, making documentation specialist one of the more accessible entry points for people moving directly from school into a writing-focused career.
Which industries hire the most entry level documentation specialists?
Entry Level documentation specialist roles concentrate in Healthcare & Medical Services, Insurance, and Science & Research, based on current listings on Migrate Mate as of July 2026. Those sectors generate consistent demand at the junior level because they rely on accurate, up-to-date procedures, compliance materials, and user guides that require dedicated writers rather than subject-matter experts doubling as documentarians.