Jobs in the United States

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Manager Registered Med Surg Urology
Ascension
Waco, TX
Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources
Added just now
Agentic automation, Frontier AI
Eli Lilly and Company
United States
…medicines to those who need them, improve the understanding and management of disease, and give back to our communities through philanthropy and volunteerism. We give our best effort to our…
Added 1 min ago
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Associate Care Director (WA)
Aegis Living
Seattle, WA
- $26 to $27 USD / hour
Ongoing Training Programs to Advance Your Career in Healthcare (Up to 100+ hours of training in the 1st year)
Added 1 min ago
E
Personal Trainer, Mission District
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San Francisco, CA
- $19.61 USD / hour
Pathway to management opportunities via our in-house Manager-In-Training program.
Added 1 min ago
Account Executive
RNA Rentokil North America
Peoria, IL · Champaign, IL
The primary purpose of this role is to sell the company's industry leading pest management services and products to new and existing commercial customers, while maintaining a…
Added 2 mins ago
Senior Director, Integrated Local Media Planning
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United States
…media that matters most, with $4 billion in digital media under management and more than 1,200 employees. Built for marketers who demand growth and accountability, Tinuiti unites media and…
Added 2 mins ago
Specialist, Pre-Apprenticeship
Foundation for California Community Colleges
Remote, United States
…shadowing, classroom presentations, internships, and other job training…
Added 3 mins ago
Principal / Senior Principal Logistics Engineer
CORP-Corporate Office
United States
Support logistics engineering activities and assist as a technical resource from a program’s concept and proposal phases through development, test, production, and post-production support…
Added 3 mins ago
Principal Product Support Engineer - Supportability (LSA)
CORP-Corporate Office
United States
Please note that this opportunity is contingent on program funding. Start dates are determined after funding confirmation.
Added 4 mins ago
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Assistant Store Manager - Nike Folsom
Nike
Folsom, CA
- $70,700 to $106,100 USD / year
…passion for sport and customer service. This includes properly training your team and implementing our Service Principles while representing our global culture of sport, the NIKE brand,…
Added 5 mins ago
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Supervisor, Water Quality | Full-Time | SeaWorld San Diego
Sea World LLC
United States
- $37 USD / hour
- Full-time
Responsible for transitioning and training of new hires
Added 5 mins ago
SW
Supervisor, Entertainment | Full-Time | Sesame Place
Sea World LLC
United States
- $22.75 USD / hour
- Full-time
Developing the training and maintenance of safety inspections and procedures for your assigned venue(s)/area(s). This includes, but is not limited to, green tag procedure, injury reduction…
Added 5 mins ago
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Project Specialist | Full-Time | SeaWorld San Diego
Sea World LLC
United States
- Full-time
Required Skills, Knowledge, Education and Training
Added 5 mins ago
General Manager
Applied Industrial Technologies - PA LLC
Williamsport, PA
· Personalized training and development program
Added 5 mins ago
General Manager
Applied Industrial Technologies, Inc.
Fairmont, WV
· Personalized training and development program
Added 5 mins ago
Primary Care RN or LPN - Mercy Clinic Des Peres
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United States
Must complete a minimum of three months of on-site training prior to transitioning to a hybrid work-from-home schedule. After training, this role follows a 50/50 hybrid model, with…
Added 5 mins ago
EN
Direct Support Professional – Community Adult Program-1
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Dublin, CA
- $21 to $22 USD / hour
Under the direction of the Care Coordinator, Assistant Program Manager and Program Manager, the Direct Support Professional works with adult learners with intellectual and developmental…
Added 5 mins ago
EN
Direct Support Professional - Community Adult Program
Easterseals Northern California
Dublin, CA
- $21 to $22 USD / hour
Under the direction of the Care Coordinator, Assistant Program Manager and Program Manager, the Direct Support Professional works with adult learners with intellectual and developmental…
Added 5 mins ago
EN
Direct Support Professional - Community Adult Program
Easterseals Northern California
Dublin, CA
- $21 to $22 USD / hour
Under the direction of the Care Coordinator, Assistant Program Manager and Program Manager, the Direct Support Professional works with adult learners with intellectual and developmental…
Added 6 mins ago
BB
Maintenance Tech - 1st Shift (Mon-Fri 6am - 2:30pm)
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United States
- $32.31 USD / hour
Maintain mechanical and electrical knowledge via in-going training, industry workshops, and technical reading.
Added 6 mins ago
BB
Maintenance Tech - 3rd Shift (Sun-Thu 10pm - 6:30am)
Burt's Bees Manufacturing Company
United States
- $32.31 USD / hour
Maintain mechanical and electrical knowledge via in-going training, industry workshops, and technical reading.
Added 6 mins ago
BB
Maintenance Tech - 2nd Shift (Mon-Fri 2pm - 10:30pm)
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United States
- $32.31 USD / hour
Maintain mechanical and electrical knowledge via in-going training, industry workshops, and technical reading.
Added 7 mins ago
Mechatronics and Robotics Apprentice
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401(k) Retirement Program with Employer Match
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Fiscal Program Analyst - Department Promotional Only (AG Department)
County of Colusa
Colusa, CA
- $28.07 to $46.05 USD / hour
To perform a variety of fiscal management services and activities; and to coordinate the operation of a fiscal program for the Ag Department.

CLINICAL DOCUMENTATION SPEC

OH, United States

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Job details

Education: Bachelor’s degree
Experience: 3 to 5 years of related experience required.
Posting language: English

Original job description

If you are motivated by the opportunity to make a meaningful impact on patient care while using your clinical knowledge and analytical skills, this Clinical Documentation Specialist role at Premier Health offers a highly rewarding career path. In this position, you will help ensure the medical record accurately reflects each patient’s severity of illness, the services provided, and the quality of care delivered. Your expertise will directly support compliant documentation, accurate coding, and improved outcomes across the healthcare continuum. Premier Health offers the chance to join an organization known for its commitment to excellence, collaboration, and service. As a respected healthcare employer, Premier Health fosters a professional environment where employees are supported in their growth, encouraged to contribute ideas, and recognized for the value they bring to patients, providers, and the broader care team. This role is ideal for a clinically knowledgeable and detail-oriented professional who wants to work at the intersection of patient care, documentation integrity, and healthcare quality. In this position, you will feel connected through close collaboration with physicians, nursing teams, ancillary departments, and coding professionals. Your work will play a vital role in strengthening communication across disciplines and ensuring the clinical picture is clearly and accurately documented. Employees who thrive at Premier Health value the teamwork-oriented culture, the meaningful nature of the work, and the opportunity to contribute to organizational goals that support patient satisfaction, compliance, and operational excellence. The Clinical Documentation Specialist is responsible for facilitating accurate and compliant documentation by improving the overall quality and completeness of the medical record. Through utilization of clinical expertise, this role ensures the patient’s severity of illness is captured in the medical record. The specialist guides physicians, nursing, and ancillary staff on clinical documentation best practices and works closely with coding professionals to ensure the coding summary reflects the level of service provided. This position requires a broad clinical knowledge base to accurately review the patient medical record for diagnosis clarification, principal diagnosis accuracy, and capture of additional comorbid conditions, including HACs, focused PSIs, and Vizient risk-adjusted diagnoses.

Analyze clinical documentation for assigned patients and make recommendations for appropriate DRG assignment.
Facilitate appropriate clinical documentation to support accurate diagnosis coding and ensure the level of service rendered is fully recorded.
Complete admission reviews with the most appropriate principal diagnosis, complicating conditions, and supporting documentation to reflect severity of illness in compliance with government regulations.
Identify opportunities for documentation clarification and complete clinically based queries.
Perform timely follow-up on outstanding queries and document outcomes appropriately.
Prioritize and utilize time effectively while adhering to employment policies and productivity expectations.
Participate as a team member in achieving department-specific goals and metrics.
Maintain required training, competencies, and educational requirements, including Healthstream assignments.
Support the professional development of peers, care team members, and orientees while participating in performance improvement activities.
Complete initial and follow-up medical record reviews using an organized approach across admit notes, medical history, medications, provider documentation, treatments, orders, ancillary notes, and laboratory data.
Analyze and interpret clinical data to identify documentation gaps, inconsistencies, and opportunities for improvement using the concurrent query process.
Formulate credible clinical documentation clarifications related to principal diagnosis, co-morbidities, POA status, quality core measures, and PSIs.
Assign appropriate DRG/APR-DRG, MCCs, and CCs to each reviewed record in the CDI documentation system using coding rules and guidelines.
Educate providers regularly to enhance understanding of the Clinical Documentation Improvement program.
Collaborate with clinical disciplines and coding department staff to promote high-quality documentation and timely coding.
Conduct post-discharge reviews for comparative analysis of CDI Specialist and Coding DRG assignment.
Develop collaborative relationships and promote teamwork with coworkers and other departments.
Organize and perform work responsibilities effectively and efficiently.
Maintain strict patient confidentiality in adherence with HIPAA guidelines.
Demonstrate Premier Health’s strategic goals and behavioral expectations, including teamwork, communication, compassion, accountability, and service excellence.

The Clinical Documentation Specialist is responsible for facilitating complete and compliant documentation. Through utilization of their clinical expertise they ensure the patient’s severity of illness is accurately portrayed in the medical record. They are responsible for guiding physicians, nursing, and ancillary staff on clinical documentation best practices and working closely with the coding professionals to increase coding accuracy.

Bachelor’s degree required.
Bachelor of Science in Nursing, Health Information Management, or equivalent medical degree preferred. Area of study in Nursing, HIM, or as a medical college graduate.
Current license to practice professional nursing in the State of Ohio or reciprocal states; or USMLE/ECFMG certification for foreign-trained graduates, as applicable.
Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) certification preferred.
3 to 5 years of related experience required.
Previous experience as a Nurse, Coder, or medical college graduate strongly preferred. Strong critical thinking, problem-solving, and analytical skills with the ability to integrate knowledge. Exemplary interpersonal skills with the ability to build rapport with physicians, peers, and healthcare team members. Negotiation, conflict resolution, and assertive communication skills required. Ability to multi-task and work effectively with interruptions. Teamwork oriented with strong professionalism, tact, and diplomacy. Strong organizational, analytical, and prioritization skills. Effective oral and written communication skills.

High degree of confidentiality required. Basic computer knowledge and skills required. Broad clinical knowledge base necessary to review a wide variety of medical records. Proficiency in EPIC, 3M, Midas, CDE One, and other related software programs. Knowledge of ICD-10 coding required.

Education: BSN required Licensure: Registered Nurse with valid Ohio license Certification: Certification in Clinical documentation, CPHQ, or Case Management preferred Experience: Minimum of three years of relevant clinical experience in area of patient population within last five years. Solid working knowledge of healthcare reimbursement preferred. Skills/Other: Strong critical thinking, problem solving, and analytical skill with the ability to integrate knowledge is required. Exemplary interpersonal skills as demonstrated by the ability to develop and maintain rapport with physicians, peers, and other members of the healthcare team. Negotiation skills, conflict resolution skills and assertive communication skills required. Computer skills expected.

If you are ready to bring your clinical expertise, coding knowledge, and documentation improvement skills to a respected healthcare organization, consider applying for the Clinical Documentation Specialist opportunity at Premier Health. This is your chance to join a collaborative team where your work will influence care quality, compliance, and patient outcomes every day. Apply now to take the next step in a meaningful and professionally rewarding career.

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