Clinical Documentation Integrity Specialist

University Hospitals

. Facilitate the integrity, quality, accuracy, and completeness of provider-based clinical documentation in medical records .

Posted 10/17/2026full-timeRemote • Ohio • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation integrity (CDI) and coding practices, with a strong focus on AHIMA compliance and healthcare workflow optimization. Proficient in collaborating with clinical teams to enhance medical record accuracy and quality outcomes.

Highest-signal resume keywords

Clinical Documentation Integrity (CDI)ICD-10 Coding ExperienceAHIMA ComplianceRegistered Nurse (RN) LicenseClinical Computer Systems Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewMedical Record AnalysisQuery WritingPathology KnowledgePharmacology KnowledgeSurgical Procedures KnowledgeDRG AssessmentRevenue Cycle AnalysisQuality Outcome ReportingCoding Guidelines Knowledge

Soft Skills

Excellent Communication SkillsDetail-OrientedRelationship-Building SkillsTeam PlayerIndependent Functioning

Tools & Technologies

CDI Business PlatformClinical Computer Systems

Certifications & Qualifications

Registered Nurse (RN)RHIARHIT

Industry Keywords

Protected Health Information (PHI)Healthcare WorkflowCoding ClinicsCMS GuidelinesDisease Pathophysiology

About the role

Key responsibilities & impact

Facilitate the integrity, quality, accuracy, and completeness of provider-based clinical documentation in medical records
Collaborate with healthcare providers and clinical teams to ensure documentation accurately reflects patients
Review medical records and identify opportunities for improved or clarified documentation
Follow up with clinical providers to obtain requested clarification
Maintain current CDI and coding knowledge, including research, technology, treatment modalities, Coding Clinics, AHIMA, and CMS guidelines
Identify query opportunities and write AHIMA-compliant physician queries
Escalate non-response to queries according to policy
Collaborate with the coding team
Educate physicians and clinical care providers through rounding, service-line sessions, and case-specific feedback
Apply healthcare workflow knowledge to improve medical record documentation and quality-outcome reporting
Meet productivity, quality, and AHIMA ethical standards using the CDI business platform
For inpatient work: review encounters, determine working DRGs, assess SOI/ROM cases, identify HAC/PSI queries, and reduce DRG downgrade and denial risks
For outpatient work: research missing charges, coordinate with Coding/CDM/Finance, analyze clinical and billing data, maintain project plans, track revenue indicators, and audit defined areas
Perform other assigned duties and comply with policies and PHI requirements

Requirements

What you’ll need

Associate's Degree in health related field (Required) or Diploma in Nursing from an accredited program (Required)
3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required)
1+ years experience using clinical computer systems (Required)
Thorough, up-to-date clinical skills, including pathology, pharmacology, and surgical procedures
Excellent written and verbal communication skills, including presentations
Ability to function independently and as a team player in a fast-paced environment
Detail-oriented and relationship-building skills
Extensive knowledge of disease pathophysiology
Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire), or RHIA (Required Upon Hire), or RHIT (Required Upon Hire)
Must safely and securely maintain Protected Health Information (PHI)
10% travel requirement