Clinical Documentation Improvement Specialist

Cooper University Hospital

. Review inpatient medical records concurrently to ensure clear, consistent, concise, legible, and accurate documentation reflecting patients’ severity of illness and intensity of services .

Posted 11/11/2026full-timeRemote • New Jersey • United StatesMid-LevelSenior💰 $34 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical documentation improvement, ensuring accurate and compliant medical records while collaborating effectively with healthcare teams. Proficient in analyzing clinical information and providing educational support to enhance documentation practices.

Highest-signal resume keywords

Clinical Documentation ImprovementMedical Record ReviewCollaboration with Healthcare TeamsEducational Support for Clinical StaffCertified Clinical Documentation Specialist Certification

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical AnalysisDocumentation AuditingQuery GenerationDRG Accuracy ImprovementMedical Necessity Review

Soft Skills

Effective CommunicationTeam CollaborationInterpersonal Skills

Certifications & Qualifications

Certified Clinical Documentation Specialist CertificationCertified Documentation Improvement PractitionerRegistered Nurse

Industry Keywords

Inpatient Medical RecordsClinical SeverityHealth Information ManagementReimbursement ProcessesDocumentation Modifications

About the role

Key responsibilities & impact

Review inpatient medical records concurrently to ensure clear, consistent, concise, legible, and accurate documentation reflecting patients’ severity of illness and intensity of services
Generate and utilize queries to clarify physician documentation when medical records contain conflicting, ambiguous, or incomplete information about significant reportable conditions or procedures
Analyze clinical information to identify gaps in clinical documentation
Utilize the physician advisor to clarify clinical presentation
Collaborate with HIM Leadership, coders, Coding Quality Educators/Reviewers, and peers to improve final DRG accuracy
Provide educational support to physicians, nurses, and ancillary staff to improve clinical documentation processes
Facilitate documentation modifications through interaction with physicians, nursing staff, caregivers, and Health Information coding staff to capture appropriate reimbursement and clinical severity
Review cases denied for medical necessity by auditing agencies and assist the physician advisor with appeals by collecting pertinent information

Requirements

What you’ll need

3-5 years of experience required
High School/GED Required
Bachelor's Degree Required
Certified Clinical Documentation Specialist Certification preferred
Certified Documentation Improvement Practitioner preferred
Registered Nurse, any state, preferred
Professional team player, able to communicate well with others on all levels required