Clinical Documentation Specialist

2 weeks ago


Kansas City, United States North Kansas City Hospital Full time

SUMMARY: The Clinical Documentation Improvement Specialist performs patient record reviews concurrently and retrospectively to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Additional responsibilities include: Presents queries to physicians when needed to clarify ambiguous or incomplete documentation. The Clinical Documentation Improvement Specialist validates the assigned working Diagnosis Related Group (DRG) to support the operations of Utilization Review and Care Coordination functions. Formulates, interprets, and analyzes data relative to opportunities to improve documentation practices, including impact to Diagnosis Related Group, Risk of Mortality and Severity of Illness. Educates physicians and advanced practice professionals on best practice clinical documentation. EXPERIENCE: Clinical Documentation Integrity, strong understanding of clinical indicators and their impact on SOI/ROM and documentation specificity. Basic working knowledge of ICD-10-CM diagnosis coding. Experience with mortality reviews and quality-driven documentation practices. Experience collaborating with HIM coding professionals. Knowledge of or exposure to Solventum/Oracle is a plus but not required. SPECIAL SKILLS: Excellent critical thinking and effective communication skills; organized, flexible and able to juggle multiple tasks simultaneously. Ability to educate peers and other clinical professionals. Knowledge of Milliman Criteria or InterQual Criteria a bonus. OTHER: Demonstrates proactive self-starter activities and initiates opportunities for efficiency and improvement. Proficient in using electronic medical records, MS Office products and other clinical software. LICENSE/CERT: Required: RN (Registered Nurse) State of Missouri, BLS (Basic Life Support) from AHA (American Heart Association), CCDS (Certified Clinical Documentation Specialist) within 2 years of hire, CDIP (Certified Documentation Improvement Practitioner) within 2 years of hire EDUCATION: Required: Bachelors - Nursing, Preferred: Masters - Nursing Required Preferred Job Industries Healthcare



  • Kansas City, United States North Kansas City Hospital Full time

    SUMMARY: The Clinical Documentation Improvement Specialist performs patient record reviews concurrently and retrospectively to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Additional responsibilities include: Presents queries to physicians when needed to clarify ambiguous...


  • Kansas City, United States North Kansas City Hospital Full time

    SUMMARY: The Clinical Documentation Improvement Specialist performs patient record reviews concurrently and retrospectively to determine complete, accurate and timely documentation of all conditions that support hospitalization and treatment of the patient. Additional responsibilities include:Presents queries to physicians when needed to clarify ambiguous or...


  • Kansas City, United States Saint Luke's Health System Full time

    Job Description ​The Opportunity:Saint Luke's is looking for a Clinical Documentation Specialist to review medical record documentation to ensure appropriate representation of severity of illness, complications, comorbidities, and clinical support. This person will educate clinical providers on accurate and compliant medical record documentation. A...


  • Kansas City, United States The University of Kansas Health System Full time

    Position TitleClinical Documentation Integrity Specialist - InpatientRemotePosition Summary / Career Interest:The Clinical Documentation Integrity Specialist - Inpatient (CDS) will review inpatient medical records as directed on admission and throughout hospitalization for completeness and accuracy for severity of illness (SOI) and risk of mortality (ROM)....


  • Iowa City, Iowa, United States The University of Iowa Full time

    The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full-time Clinical Documentation Specialist. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation...

  • Travel Nurse RN

    1 week ago


    Kansas City, United States Care Career Full time

    Care Career is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Kansas City, Kansas.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: 11/10/2025Duration: 13 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelExperience Required: Minimum 3...


  • Oklahoma City, OK, United States OU Health - The Childrens Hospital - Oklahoma City - Rightsourcing Full time

    DetailsClient Name OU Health - The Childrens Hospital - Oklahoma City - Rightsourcing Job Type Travel Offering Non-Clinical Profession Admin / Non-Clerical Specialty Clinical Documentation Specialist Job ID 34608060 Job Title Admin / Non-Clerical - Clinical Documentation Specialist Shift DetailsShift 8 Hour Days - 8AM Start Scheduled Hours 40 Job Order...


  • Oklahoma City, OK, United States OU Health - The Childrens Hospital - Oklahoma City - Rightsourcing Full time

    DetailsClient Name OU Health - The Childrens Hospital - Oklahoma City - Rightsourcing Job Type Travel Offering Non-Clinical Profession Admin / Non-Clerical Specialty Clinical Documentation Specialist Job ID 34608060 Job Title Admin / Non-Clerical - Clinical Documentation Specialist Shift DetailsShift 8 Hour Days - 8AM Start Scheduled Hours 40 Job Order...


  • Oklahoma City, United States MidFirst Bank Full time

    The Documentation Specialist is responsible for mitigating bank risk by ensuring properly executed original documentation is returned as well as ensuring the loan system appropriately identifies whether the loan is pledgeable to bank regulatory autho Specialist, Monitoring, Skills, Banking, Healthcare, Collateral


  • Jefferson City, Missouri, United States American Unit, Inc Full time $60,000 - $90,000 per year

    Technical Documentation SpecialistWe are seeking an experiencedTechnical Documentation Specialistto support a large-scale state technology initiative. The ideal candidate will bring strong writing, requirements documentation, and editing skills, along with experience supporting IT teams in a structured project environment.Key ResponsibilitiesDevelop, review,...