Clinical Documentation Specialist

•CDI Indiana University Health

•3.7 Indianapolis, IN Job Details Full-time 12 hours ago Benefits Health insurance Dental insurance Tuition reimbursement Employee assistance program Vision insurance Retirement plan Qualifications Desktop applications Associate's degree Full Job Description Clinical Documentation Specialist

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CDI Job Description Overview Location:

Remote Position:

Clinical Documentation Specialist

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CDI Shift:

Monday

•Friday; Start times are flexible IU Health is Indiana's largest and most comprehensive healthcare system, and the #1 ranked healthcare provider in the state. We are seeking a dedicated professional to improve the quality and completeness of clinical documentation, supporting accurate coding, quality measurement, and patient care outcomes.

Position Overview:

The Clinical Documentation Specialist enhances the overall quality and accuracy of clinical documentation on a concurrent and retrospective basis through daily review and interactions with physicians and healthcare providers. They utilize clinical and coding expertise to analyze documentation, ensuring it accurately reflects the level of service provided. This role supports timely and precise capture of quality metrics to improve patient care, physician documentation, and hospital outcomes.

Key Responsibilities:

Perform daily review of clinical documentation and interact with physicians and providers to ensure completeness and accuracy. Analyze and evaluate documentation to ensure it reflects appropriate levels of care and supports quality measures. Support timely coding and documentation processes to optimize hospital and physician performance metrics. Collaborate with clinical teams to identify documentation gaps and implement improvement strategies. Stay current with coding guidelines, documentation standards, and quality measurement requirements. Maintain compliance with regulatory and accreditation standards related to clinical documentation. Support education and training initiatives for staff regarding documentation best practices. Utilize clinical and coding expertise to support continuous quality improvement initiatives.

Qualifications & Requirements:

Associate's Degree required; Bachelor's Degree preferred. 0-3 years of relevant experience in clinical documentation, coding, or related fields. Active Registered Nurse (RN) license in Indiana or Nurse Licensure Compact (NLC) RN license, or RHIA/RHIT and/or CCS certification. If RN licensed, 3-5 years of strong, varied clinical experience in an acute care setting preferred. CCDS and/or CDIP credential preferred; obtain within 4 years of hire. Ability to work independently and produce high-quality outcomes. Working knowledge of computers and software applications such as Microsoft Office Suite (Outlook, Word, Excel, PowerPoint, SharePoint, Teams) and Cerner EMR. Ability to sit for extended periods. Position is remote but may require occasional on-site meetings with advanced notice. Why Join IU Health? Comprehensive benefits package including health, dental, and vision insurance Retirement savings plan with employer match Tuition reimbursement and professional development opportunities Employee assistance programs and wellness initiatives Supportive work environment committed to safety and excellence To learn more about our benefits, visit: careers.iuhealth.org/pages/benefits-designed-for-you We are an equal opportunity employer. IU Health does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation. Qualifications for the Clinical Documentation Specialist

•

CDI Role Overview Location:

Remote Position:

Clinical Documentation Specialist

•

CDI Shift:

Monday

•Friday; Start times are flexible IU Health is Indiana's largest and most comprehensive healthcare system, and the #1 ranked healthcare provider in the state. We are seeking a dedicated professional to improve the quality and completeness of clinical documentation, supporting accurate coding, quality measurement, and patient care outcomes.

Position Overview:

The Clinical Documentation Specialist enhances the overall quality and accuracy of clinical documentation on a concurrent and retrospective basis through daily review and interactions with physicians and healthcare providers. They utilize clinical and coding expertise to analyze documentation, ensuring it accurately reflects the level of service provided. This role supports timely and precise capture of quality metrics to improve patient care, physician documentation, and hospital outcomes.

Key Responsibilities:

qualifications__list Perform daily review of clinical documentation and interact with physicians and providers to ensure completeness and accuracy. Analyze and evaluate documentation to ensure it reflects appropriate levels of care and supports quality measures. Support timely coding and documentation processes to optimize hospital and physician performance metrics. Collaborate with clinical teams to identify documentation gaps and implement improvement strategies. Stay current with coding guidelines, documentation standards, and quality measurement requirements. Maintain compliance with regulatory and accreditation standards related to clinical documentation. Support education and training initiatives for staff regarding documentation best practices. Utilize clinical and coding expertise to support continuous quality improvement initiatives.

Qualifications & Requirements:

Associate's Degree required; Bachelor's Degree preferred. 0-3 years of relevant experience in clinical documentation, coding, or related fields. Active Registered Nurse (RN) license in Indiana or Nurse Licensure Compact (NLC) RN license, or RHIA/RHIT and/or CCS certification. If RN licensed, 3-5 years of strong, varied clinical experience in an acute care setting preferred. CCDS and/or CDIP credential preferred; obtain within 4 years of hire. Ability to work independently and produce high-quality outcomes. Working knowledge of computers and software applications such as Microsoft Office Suite (Outlook, Word, Excel, PowerPoint, SharePoint, Teams) and Cerner EMR. Ability to sit for extended periods. Position is remote but may require occasional on-site meetings with advanced notice. Why Join IU Health? Comprehensive benefits package including health, dental, and vision insurance Retirement savings plan with employer match Tuition reimbursement and professional development opportunities Employee assistance programs and wellness initiatives Supportive work environment committed to safety and excellence To learn more about our benefits, visit: careers.iuhealth.org/pages/benefits-designed-for-you Indiana University Health is Indiana's most comprehensive health system, with 15 hospitals and nearly 40,000 team members serving Hoosiers across the state. Our partnership with the Indiana University School of Medicine gives our team members access to the very latest science and the very best training, advancing care for all. We're looking for team members who share the things that matter most to us. People who are inspired by challenging and meaningful work for the good of every patient. People who are compassionate and serve with a purpose. People who aspire to excellence every day. People who are always ready to apply themselves.