Clinical Documentation Integrity Specialist – Out Patient

University Hospitals

. Review outpatient medical records and identify documentation, coding, and charging opportunities .

Posted 10/14/2026full-timeRemote • Ohio • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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

Demonstrates expertise in clinical documentation improvement, coding accuracy, and compliance with AHIMA standards. Proficient in analyzing clinical and billing data to enhance revenue cycle management and educate healthcare providers.

Highest-signal resume keywords

ICD-10 Coding ExperienceClinical Documentation ImprovementRegistered Nurse (RN) LicenseClinical Computer Systems ExperiencePathology Knowledge

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 DocumentationCoding ExpertiseData AnalysisAudit and MonitoringRevenue Cycle ManagementPatient Clinical Data ReviewAHIMA ComplianceDocumentation StandardsMissed Charge IdentificationProject Management

Soft Skills

Excellent Communication SkillsDetail-OrientedRelationship-BuildingTeam CollaborationIndependent Functioning

Certifications & Qualifications

Registered Nurse (RN)RHIARHIT

Industry Keywords

Protected Health Information (PHI)Clinical Care ProvidersHealthcare TeamsAcademic Medical CenterDisease Pathophysiology

About the role

Key responsibilities & impact

Review outpatient medical records and identify documentation, coding, and charging opportunities
Ensure provider-based clinical documentation is accurate, complete, timely, and reflects the patient
Apply clinical and/or coding expertise to identify opportunities for improved or clarified documentation
Follow up with clinical providers to obtain requested clarifications
Write AHIMA-compliant physician queries and escalate non-responses according to policy
Collaborate with coding, clinical, finance, CDM, and other healthcare teams
Educate physicians and clinical care providers through rounding, service-line education, and case-specific feedback
Analyze patient clinical and billing data to identify missed charges and root causes
Summarize data and prepare materials for clinical and finance team discussions
Develop and maintain project plans, meeting documentation, and issue tracking
Work with finance to track revenue indicators and action plans
Audit and monitor defined areas
Meet productivity, quality, AHIMA ethical, and operational standards
Safely and securely maintain Protected Health Information (PHI)
Perform other duties as assigned

Requirements

What you’ll need

Associate's Degree in health related field or Diploma in Nursing from an accredited program (Required)
Bachelor's Degree in health related field (Preferred)
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)