Documentation Specialist jobs in United States

Explore 22 matching jobs.

Ochsner Health

RN Clinical Documentation Specialist Lead – Quality Reviewer

Ochsner Health

Posted: 10/21/2026
NewYork-Presbyterian Hospital

Documentation Improvement Specialist, CDI

NewYork-Presbyterian Hospital

Posted: 10/21/2026
Axos Bank

Documentation Specialist III

Axos Bank

Posted: 10/14/2026
CCC Intelligent Solutions

Technical Product Documentation Specialist

CCC Intelligent Solutions

Posted: 10/14/2026
Pinnacle Home Care

Documentation Management Specialist

Pinnacle Home Care

Posted: 10/13/2026
Dhaka Technologies Limited Company

Interface Specialist – ICD Documentation

Dhaka Technologies Limited Company

Posted: 10/10/2026
NoSQLSQL
ACU-Serve

DME Documentation Specialist

ACU-Serve

Posted: 10/8/2026
ERMCO-ECI

Technical Documentation Specialist

ERMCO-ECI

Posted: 10/5/2026
CloudCyber Security
Pinnacle Home Care

Documentation Specialist – Health Care

Pinnacle Home Care

Posted: 9/29/2026
City National Bank of Florida

Technical Documentation Specialist

City National Bank of Florida

Posted: 9/28/2026
VBA
Pinnacle Home Care

Documentation Specialist – Health Care

Pinnacle Home Care

Posted: 9/25/2026
Ambry Genetics

R&D Assay Documentation Specialist

Ambry Genetics

Posted: 9/25/2026
WEP Clinical

Documentation Specialist

WEP Clinical

Posted: 9/25/2026
Pinnacle Home Care

Documentation Specialist – Health Care

Pinnacle Home Care

Posted: 9/25/2026
DISA Global Solutions, Inc.

Documentation Specialist

DISA Global Solutions, Inc.

Posted: 9/22/2026
Pinnacle Home Care

Documentation Management Specialist

Pinnacle Home Care

Posted: 9/18/2026
NOV

Documentation Specialist

NOV

Posted: 9/18/2026
ERP
AdaptHealth

Documentation Specialist

AdaptHealth

Posted: 9/18/2026
Tempus AI

R&D Assay Documentation Specialist

Tempus AI

Posted: 9/17/2026
Pinnacle Home Care

Documentation Specialist – Health Care

Pinnacle Home Care

Posted: 9/17/2026
Pinnacle Home Care

Documentation Specialist - Home Health Care

Pinnacle Home Care

Posted: 9/17/2026
Ochsner Health

RN Clinical Documentation Specialist Lead – Quality Reviewer

Ochsner Health
Posted 10/21/2026full-timeRemote • Louisiana • United StatesSeniorWebsite
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Core Competencies

Role fit
Core Competencies

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

Demonstrates advanced clinical expertise and extensive knowledge of complex disease processes, with a focus on Clinical Documentation Improvement and effective communication with internal and external customers. Proficient in operational reporting and departmental workflow management to support performance improvement initiatives.

Highest-signal resume keywords
Registered Nurse LicenseClinical Documentation Improvement ExperienceCertified Clinical Documentation Specialist (CCDS)Effective Communication SkillsOrganizational Skills

About the role

Key responsibilities & impact
  • Serve as liaison between CDI Department customers and CDI Leadership
  • Act as a clinical and technical resource for CDS staff
  • Answer questions and provide guidance on non-administrative issues
  • Observe, report, prioritize, and reroute daily departmental workflow under leadership direction
  • Run operational reports and forward key metrics to leadership at scheduled intervals
  • Facilitate special record reviews, projects, and customer requests
  • Perform medical record reviews throughout patient stays for documentation completeness and accuracy
  • Communicate with internal and external customers
  • Provide consultation and education to departmental staff
  • Support and participate in physician/hospital performance improvement initiatives
  • Assist the department manager with departmental initiatives
  • Perform other related duties as required

Requirements

What you’ll need
  • Completion of a formal training program in Nursing
  • Current State of Louisiana Registered Nurse License
  • 3 years of clinical experience in an acute care setting, including experience in Clinical Documentation Improvement
  • Advanced clinical expertise and extensive knowledge of complex disease processes with broad inpatient clinical experience
  • Computer skills and dexterity for patient-information data entry and retrieval
  • Proficiency with Windows-style applications and keyboard
  • Effective verbal and written communication skills
  • Broad-based clinical knowledge and understanding of pathology/physiology of disease processes
  • Strong organizational skills
  • Self-directed
  • Bachelor’s degree in Nursing preferred
  • Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) preferred

Benefits

Comp & perks
  • Equal Opportunity Employer
  • Reasonable accommodations for individuals with disabilities
  • Remote work arrangement for eligible locations

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills
Clinical ExpertiseMedical Record ReviewData EntryOperational ReportingDocumentation CompletenessPathology KnowledgePhysiology KnowledgeInpatient Clinical ExperienceWorkflow ManagementPatient Information Retrieval
Soft Skills
Self-DirectedEffective Verbal CommunicationEffective Written Communication
Tools & Technologies
Windows-Style Applications
Certifications & Qualifications
Certified Clinical Documentation Specialist (CCDS)Certified Documentation Improvement Practitioner (CDIP)
Industry Keywords
Clinical Documentation ImprovementAcute Care SettingPerformance Improvement InitiativesDepartmental InitiativesCustomer Requests