Clinical Documentation Improvement Jobs in USA with Visa Sponsorship
Clinical Documentation Improvement specialists are in steady demand at hospitals and health systems that sponsor H-1B visa and TN visas for qualified candidates. Most roles require a clinical background plus a CCS, CIC, or CDIP credential, and employer sponsorship is common at larger institutions. For detailed occupation requirements, see the O*NET profile.
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Get Access To All JobsPosition Summary:
The Clinical Documentation Improvement Specialist (CDIS) conducts concurrent reviews of inpatient medical records to enhance the quality, accuracy, and completeness of documentation. Utilizing clinical expertise and current coding systems (ICD-10-CM & PCS), the CDIS ensures proper code assignment and alignment with the patient’s clinical condition and care provided. The role involves collaborating with providers through education and the physician query process to support severity of illness, quality metrics, and regulatory compliance. Additionally, the CDIS maintains expertise in coding principles, government regulations, and third-party requirements while serving as a resource for clinicians, coders, and Revenue Cycle teams.
Minimum Qualifications:
Required
- Bachelor's degree in Nursing (RN) with current Registered Nurse (RN) licensure; OR
- Graduate of an accredited or equivalent international medical program or advanced medical program (MD, DO, NP, MBBS or equivalent); OR
- Ten (10) years of experience in Clinical Documentation Improvement (CDI) in an acute care setting
- At least one of the following CDI or coding credentials/certifications:
- Certified Coding Specialist (CCS)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
Preferred
- Three (3) years of experience in one of the following areas:
- Medical/Surgical or Critical Care nursing.
- Clinical Documentation Improvement (CDI) or Inpatient Coding in an acute care setting.
- Experience with Epic and 3M 360 Encoder systems.
Essential Job Functions:
In addition to the essential functions of the job listed below, employees must have on-time completion of all required education as assigned per DNV requirements, Bozeman Health policy, and other registry requirements.
- Ensure ethical, accurate, and complete coding by adhering to current coding practices, guidelines, and conventions when assigning DRGs, diagnoses, and procedures.
- Conduct concurrent medical record reviews for inpatient admissions, assigning a working principal diagnosis, secondary diagnoses, procedures, and DRG.
- Follow CDI processes for querying providers, reconciling DRG or diagnosis assignments with facility coders, and resolving physician queries before patient discharge.
- Collaborate with healthcare professionals, including physicians, advanced practice providers, case managers, and coders, to ensure documentation accurately reflects severity of illness, risk of mortality, and level of services provided.
- Utilize designated clinical documentation systems (e.g., 3M 360, Epic) to identify documentation improvement opportunities and enhance hospital outcomes.
- Identify medical record data integrity issues and escalate concerns related to coding, CDI functions, or electronic health record (EHR) systems to the appropriate department.
- Maintain compliance with HIPAA regulations to ensure data security and patient confidentiality.
- Participate in team, clinician, and interdepartmental meetings, as well as training, shadowing, and education initiatives for staff related to compliance, coding, and CDI best practices.
- Provide education and act as a consultant to coders and clinical staff when additional documentation or clarification is needed for accurate DRG assignment and coding compliance.
- Identify and recommend process improvements and efficiencies within CDI and coding workflows while monitoring and reporting patterns, trends, and variances in documentation.
- Generate scheduled reports and other reports as requested to track CDI effectiveness and documentation trends.
- Stay up to date with CMS regulations and industry best practices, researching literature and incorporating changes into daily CDI practice.
- Meet productivity and quality standards as designated by the System Manager of CDI and complete special projects as assigned.
Knowledge, Skills and Abilities
- Demonstrates sound judgment, patience, and maintains a professional demeanor at all times
- Exercises tact, discretion, sensitivity, and maintains confidentiality
- Performs essential job functions successfully in a busy and stressful environment
- Learns current and new computer applications and office equipment utilized at Bozeman Health
- Strong interpersonal, verbal, and written communication skills
- Analyzes, organizes, and prioritizes work while meeting multiple deadlines
Schedule Requirements
- This role requires regular and sustained attendance.
- The position may necessitate working beyond a standard 40-hour workweek, including weekends and after-hours shifts.
- On-call work may be required to respond promptly to organizational, patient, or employee needs.
Physical Requirements
- Lifting (Rarely – 30 pounds): Exerting force and/or using a negligible amount of force to lift, carry, push, pull, or otherwise move objects or people.
- Sit (Continuously): Maintaining a sitting posture for extended periods may include adjusting body position to prevent discomfort or strain.
- Stand (Occasionally): Maintaining a standing posture for extended periods may include adjusting body position to prevent discomfort or strain.
- Walk (Occasionally): Walking and moving around within the work area requires good balance and coordination.
- Climb (Rarely): Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like using feet and legs; may also use hands and arms.
- Twist/Bend/Stoop/Kneel (Occasionally): Twisting, bending, stooping, and kneeling require flexibility and a wide range of motion in the spine and joints.
- Reach Above Shoulder Level (Occasionally): Lifting, carrying, pushing, or pulling objects as necessary above the shoulder, requiring strength and stability.
- Push/Pull (Occasionally): Using the upper extremities to press or exert force against something with steady force to thrust forward, downward, or outward.
- Fine-Finger Movements (Continuously): Picking, pinching, typing, or otherwise working primarily with fingers rather than using the whole hand as in handling.
- Vision (Continuously): Close visual acuity to prepare and analyze data and figures and to read computer screens, printed materials, and handwritten materials.
- Cognitive Skills (Continuously): Learn new tasks, remember processes, maintain focus, complete tasks independently, and make timely decisions in the context of a workflow.
- Exposures (Rarely): Bloodborne pathogens, such as blood, bodily fluids, or tissues. Radiation in settings where medical imaging procedures are performed. Various chemicals and medications are used in healthcare settings. Job tasks may involve handling cleaning products, disinfectants, and other substances. Infectious diseases due to contact with patients in areas that may have contagious illnesses.
The above statements are intended to describe the general nature and level of work being performed by people assigned to the job classification. They are not to be construed as a contract of any type nor an exhaustive list of all job duties performed by the personnel so classified.
LOCATION:
This position can be remote. Please review the approved remote states below.
Remote Work Approved States:
- Arizona
- Florida
- Georgia
- Idaho
- Iowa
- South Dakota
- Texas
- South Carolina
- Wisconsin
- North Carolina
-
Michigan
-
If your state is not listed, you must relocate to Montana or one of the approved states above to be eligible for this position.
Position Summary:
The Clinical Documentation Improvement Specialist (CDIS) conducts concurrent reviews of inpatient medical records to enhance the quality, accuracy, and completeness of documentation. Utilizing clinical expertise and current coding systems (ICD-10-CM & PCS), the CDIS ensures proper code assignment and alignment with the patient’s clinical condition and care provided. The role involves collaborating with providers through education and the physician query process to support severity of illness, quality metrics, and regulatory compliance. Additionally, the CDIS maintains expertise in coding principles, government regulations, and third-party requirements while serving as a resource for clinicians, coders, and Revenue Cycle teams.
Minimum Qualifications:
Required
- Bachelor's degree in Nursing (RN) with current Registered Nurse (RN) licensure; OR
- Graduate of an accredited or equivalent international medical program or advanced medical program (MD, DO, NP, MBBS or equivalent); OR
- Ten (10) years of experience in Clinical Documentation Improvement (CDI) in an acute care setting
- At least one of the following CDI or coding credentials/certifications:
- Certified Coding Specialist (CCS)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
Preferred
- Three (3) years of experience in one of the following areas:
- Medical/Surgical or Critical Care nursing.
- Clinical Documentation Improvement (CDI) or Inpatient Coding in an acute care setting.
- Experience with Epic and 3M 360 Encoder systems.
Essential Job Functions:
In addition to the essential functions of the job listed below, employees must have on-time completion of all required education as assigned per DNV requirements, Bozeman Health policy, and other registry requirements.
- Ensure ethical, accurate, and complete coding by adhering to current coding practices, guidelines, and conventions when assigning DRGs, diagnoses, and procedures.
- Conduct concurrent medical record reviews for inpatient admissions, assigning a working principal diagnosis, secondary diagnoses, procedures, and DRG.
- Follow CDI processes for querying providers, reconciling DRG or diagnosis assignments with facility coders, and resolving physician queries before patient discharge.
- Collaborate with healthcare professionals, including physicians, advanced practice providers, case managers, and coders, to ensure documentation accurately reflects severity of illness, risk of mortality, and level of services provided.
- Utilize designated clinical documentation systems (e.g., 3M 360, Epic) to identify documentation improvement opportunities and enhance hospital outcomes.
- Identify medical record data integrity issues and escalate concerns related to coding, CDI functions, or electronic health record (EHR) systems to the appropriate department.
- Maintain compliance with HIPAA regulations to ensure data security and patient confidentiality.
- Participate in team, clinician, and interdepartmental meetings, as well as training, shadowing, and education initiatives for staff related to compliance, coding, and CDI best practices.
- Provide education and act as a consultant to coders and clinical staff when additional documentation or clarification is needed for accurate DRG assignment and coding compliance.
- Identify and recommend process improvements and efficiencies within CDI and coding workflows while monitoring and reporting patterns, trends, and variances in documentation.
- Generate scheduled reports and other reports as requested to track CDI effectiveness and documentation trends.
- Stay up to date with CMS regulations and industry best practices, researching literature and incorporating changes into daily CDI practice.
- Meet productivity and quality standards as designated by the System Manager of CDI and complete special projects as assigned.
Knowledge, Skills and Abilities
- Demonstrates sound judgment, patience, and maintains a professional demeanor at all times
- Exercises tact, discretion, sensitivity, and maintains confidentiality
- Performs essential job functions successfully in a busy and stressful environment
- Learns current and new computer applications and office equipment utilized at Bozeman Health
- Strong interpersonal, verbal, and written communication skills
- Analyzes, organizes, and prioritizes work while meeting multiple deadlines
Schedule Requirements
- This role requires regular and sustained attendance.
- The position may necessitate working beyond a standard 40-hour workweek, including weekends and after-hours shifts.
- On-call work may be required to respond promptly to organizational, patient, or employee needs.
Physical Requirements
- Lifting (Rarely – 30 pounds): Exerting force and/or using a negligible amount of force to lift, carry, push, pull, or otherwise move objects or people.
- Sit (Continuously): Maintaining a sitting posture for extended periods may include adjusting body position to prevent discomfort or strain.
- Stand (Occasionally): Maintaining a standing posture for extended periods may include adjusting body position to prevent discomfort or strain.
- Walk (Occasionally): Walking and moving around within the work area requires good balance and coordination.
- Climb (Rarely): Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like using feet and legs; may also use hands and arms.
- Twist/Bend/Stoop/Kneel (Occasionally): Twisting, bending, stooping, and kneeling require flexibility and a wide range of motion in the spine and joints.
- Reach Above Shoulder Level (Occasionally): Lifting, carrying, pushing, or pulling objects as necessary above the shoulder, requiring strength and stability.
- Push/Pull (Occasionally): Using the upper extremities to press or exert force against something with steady force to thrust forward, downward, or outward.
- Fine-Finger Movements (Continuously): Picking, pinching, typing, or otherwise working primarily with fingers rather than using the whole hand as in handling.
- Vision (Continuously): Close visual acuity to prepare and analyze data and figures and to read computer screens, printed materials, and handwritten materials.
- Cognitive Skills (Continuously): Learn new tasks, remember processes, maintain focus, complete tasks independently, and make timely decisions in the context of a workflow.
- Exposures (Rarely): Bloodborne pathogens, such as blood, bodily fluids, or tissues. Radiation in settings where medical imaging procedures are performed. Various chemicals and medications are used in healthcare settings. Job tasks may involve handling cleaning products, disinfectants, and other substances. Infectious diseases due to contact with patients in areas that may have contagious illnesses.
The above statements are intended to describe the general nature and level of work being performed by people assigned to the job classification. They are not to be construed as a contract of any type nor an exhaustive list of all job duties performed by the personnel so classified.
LOCATION:
This position can be remote. Please review the approved remote states below.
Remote Work Approved States:
- Arizona
- Florida
- Georgia
- Idaho
- Iowa
- South Dakota
- Texas
- South Carolina
- Wisconsin
- North Carolina
-
Michigan
-
If your state is not listed, you must relocate to Montana or one of the approved states above to be eligible for this position.
See all Clinical Documentation Improvement Jobs
Sign up for free to unlock all listings, filter by visa type, and get alerts for new Clinical Documentation Improvement roles.
Get Access To All JobsTips for Finding Clinical Documentation Improvement Jobs
Target large health systems over small practices
Academic medical centers and multi-hospital systems like Mayo Clinic, HCA Healthcare, and Kaiser Permanente have established immigration programs and sponsor H-1B petitions for CDI specialists far more consistently than independent or small outpatient practices.
Lead with your clinical credential, not just CDI experience
Employers and USCIS both care about your clinical foundation. Holding an RN license or MD degree alongside a CDIP or CCS credential strengthens both your sponsorship case and your specialty occupation classification during petition review.
Understand how your role qualifies as a specialty occupation
CDI roles require theoretical and practical application of clinical coding standards, medical terminology, and ICD-10-CM pathophysiology. Document this clearly in your resume so the employer can build a strong specialty occupation argument in the H-1B petition.
Ask about sponsorship timeline before accepting an offer
H-1B cap-subject petitions only file in April for an October start. If your OPT or current status expires before then, ask whether the employer will pursue a cap-exempt filing or support a TN if you hold Canadian or Mexican citizenship.
Highlight remote and hybrid CDI roles in your search
Many health systems post remote CDI positions that sponsor visas, which widens your options beyond your current city. Remote roles also allow employers in high-demand states to hire nationally, improving your chances of finding a sponsoring organization.
Get your credentials evaluated if your degree is from outside the U.S.
USCIS requires that foreign degrees be equivalent to a U.S. bachelor's degree in a relevant field. A credential evaluation from a NACES-approved agency strengthens your petition and removes a common point of RFE vulnerability in CDI sponsorship cases.
Frequently Asked Questions
Do Clinical Documentation Improvement jobs typically qualify for H-1B sponsorship?
Yes, CDI specialist roles generally qualify as specialty occupations because they require a bachelor's degree or higher in a clinical, health information, or related field. USCIS has approved H-1B visa petitions for CDI roles, particularly when the job description emphasizes clinical knowledge, ICD-10-CM coding standards, and pathophysiology. Roles with a purely administrative focus carry more risk of a specialty occupation challenge, so the employer's petition language matters significantly.
Which visa types are most common for CDI specialists seeking sponsorship?
The H-1B is the most common pathway, though it requires winning the annual lottery for cap-subject positions. Canadian and Mexican nationals can pursue the TN visa under the Medical/Allied Health Professional category, which is faster and lottery-free. Some CDI roles at nonprofit hospitals or university health systems qualify as cap-exempt H-1B positions, allowing year-round filing without lottery exposure. Browse sponsoring employers on Migrate Mate to identify which institutions offer these pathways.
Is a clinical degree required, or will a Health Information Management degree work?
Either can support an H-1B petition, but the degree must align with the specific job duties. A Health Information Management or Health Informatics degree works well when the role centers on coding and documentation quality. If the position requires concurrent clinical assessment, employers often prefer RNs or physicians with CDI training. USCIS will look at whether a degree in that specific field is normally the minimum requirement for the role as posted.
How does holding a CDIP or CCS credential affect my sponsorship chances?
Credentials like the CDIP (Certified Documentation Integrity Practitioner) and CCS (Certified Coding Specialist) strengthen your petition by demonstrating specialized knowledge beyond a general degree. They support the employer's argument that the role requires specialized expertise, which is central to the specialty occupation definition. While credentials alone don't satisfy the degree requirement, they significantly reduce the risk of an RFE and signal to immigration attorneys that the petition is defensible.
Are there CDI roles that sponsor visas for candidates still on OPT?
Yes, but timing is critical. If your OPT expires before October 1 and a cap-subject H-1B is the only option, you'll face a gap in work authorization unless your degree qualifies for the 24-month STEM OPT extension. Health informatics and some health information management programs qualify as STEM. Employers who sponsor early in the OPT period give you the best chance of a smooth transition. Search current openings on Migrate Mate to find employers actively sponsoring CDI roles.
What is the prevailing wage requirement for sponsored Clinical Documentation Improvement jobs?
U.S. employers sponsoring a visa must pay at least the prevailing wage, which is what workers in the same role, area, and experience level typically earn. The Department of Labor sets this rate to make sure companies aren't hiring foreign workers simply because they'd accept lower pay than a U.S. worker. It varies by job title, location, and experience. You can look up current prevailing wage rates for any occupation and location using the OFLC Wage Search page.