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Ascension · 1 day ago

Clinical Documentation Specialist

United States

Full-time

Remote

Entry, Mid Level

$75K/yr - $105K/yr

2+ years exp

Ascension is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care. The Clinical Documentation Specialist will facilitate improvement in the quality and accuracy of medical record documentation and collaborate with healthcare professionals to ensure proper documentation.

CharityHealth CareHospitalNon Profit

H1B Sponsor Likely

Responsibilities

Facilitate improvement in overall quality, completeness and accuracy of medical record documentation

Complete admission reviews and assign a working Diagnosis Related Group. Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database

Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record

Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge

Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid

Qualification

Certified Coding Specialist (CCS)Certified Professional Coder (CPC)Clinical Documentation Prof.Registered NurseReg Health Info AdmnstrReg Health Info TechCDI experienceOB/L&D experienceQuality project collaboration

Required

One or more of the following required: Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date

One or more of the following required: Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date

One or more of the following required: Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date

One or more of the following required: Registered Nurse credentialed from the Texas Board of Nursing obtained prior to hire date or job transfer date

One or more of the following required: Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date

One or more of the following required: Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date

High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required

Preferred

CDI experience highly desirable

Recent OB and/or Labor & Delivery inpatient experience

Minimum two years of bedside OB/L&D experience

Experience collaborating or leading quality projects desirable

Benefits

Paid time off (PTO)

Various health insurance options & wellness plans

Retirement benefits including employer match plans

Long-term & short-term disability

Employee assistance programs (EAP)

Parental leave & adoption assistance

Tuition reimbursement

Ways to give back to your community

Company

Ascension

Glassdoor3.4

Answering God's call to bring health, healing and hope to all.

Founded in 1999

St Louis, Missouri, USA

10001+ employees

https://healthcare.ascension.org

H1B Sponsorship

Ascension has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (11)

2024 (7)

2023 (1)

2022 (3)