Is the Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) position at University Hospitals fully remote?

Yes, this Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) position at University Hospitals is a remote position. The role is available for candidates in United States.

What are the main requirements for the Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) role?

Key requirements include: Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment, Direct and timely follow-up with clinical providers to ensure requested clarification is provided, Utilizes critical thinking/problem solving processes, and more.

What benefits does University Hospitals offer for this position?

University Hospitals offers the following benefits: 401k Matching, Health Insurance, Paid Time Off, Remote Work.

Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) at University Hospitals

United States

Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) - (25000B99)<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Description</h2> A Brief OverviewThe Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the patient complexity and resource utilization. The CDI Specialist assesses the clinical documentation through extensive review of the medical record, interacts with multiple members of the healthcare team, educates and assists the clinical areas in effective and compliant documentation. The CDI Specialist provides guidance with processes in the clinical departments to support accurate, timely and complete documentation in agreement with company policies and procedures.What You Will Do<ul><li>Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient complexity and resource utilization. Direct and timely follow-up with clinical providers to ensure requested clarification is provided. • Responsible and accountable for expanding CDI and coding knowledge (keeping up to date on latest research, technology, treatment modalities, etc.) • Utilizes critical thinking/problem solving processes • Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines • Identifies query opportunities for record integrity • Is proficient in query writing so that the question is easily understood by the physician • Query writing is AHIMA compliant per practice briefs • Escalates non-response to query by physicians immediately according to query escalation policy • Collaborates with the coding team • Demonstrates proficiency in reviewing increasingly complex cases. • Demonstrates proficiency and efficiency in cross covering for other units, specialties and hospitals as assigned.</li><li>Actively engages in educating physicians and other clinical care providers regarding clinical documentation in a variety of formats including participation in clinical rounding, service line focused education sessions and one to one case specific feedback. • Consistently provides a collaborative relationship with healthcare team providers/members • Participates in service line rounding/touch-point routinely. • Provides ongoing service line directed education to provider teams</li><li>Applies knowledge of health care workflows in order to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes. • Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation. • Identifies opportunity utilizing resources and follows department guidelines for processes • Comprehends the impact of accurate clinical documentation in the medical record: accurate billing, public reporting, research data, quality metrics, provider scorecards, etc.</li><li>Meets established operational and productivity standards. • Consistently meets productivity, quality, and ethical standards. • Proficient and efficient use of the CDI business platform</li><li> • Serves as a mentor to other Clinical Documentation Specialists, participates in committees</li></ul>Additional Responsibilities<ul><li>Amendment for Inpatient Clinical Documentation Specialist • Performs review of facility inpatient encounters to ensure hospital case-mix index and severity profiles are accurate by performing timely medical record review, determination of working DRG assignment and applying clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness and risk of mortality of the patient. Direct and timely follow-up with clinical providers to ensure requested clarification is provided. • Demonstrates proficiency in establishing and reconciling DRG processes compliant with departmental guidelines and CMS regulations. • Demonstrates proficiency in reviewing increasingly complex (SOI and ROM) cases. • Participates in service line rounding/touch-point routinely, based on facility needs. • Identifies HAC/PSI query opportunity utilizing resources and follows department guidelines for HAC/PSI query processes • Comprehends the impact of accurate clinical documentation in the medical record beyond establishing a working DRG: accurate billing, public reporting, research data, quality metrics, provider scorecards, accuracy of the UHDDS, Case Mix Index (CMI). • Demonstrates skills of high efficiency and accuracy to identify and reduce DRG downgrades/denial risks by assuring that clinical support is beyond dispute for DRG integrity, coding and billing needs</li><li>Amendment for Outpatient Clinical Documentation Specialist • Performs review of facility outpatient encounters identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges. • Coordinates with clinical departments including Coding, CDM, Finance and others to review, correct claims and identify root cause of missing charges. • Performs analysis of patient clinical and billing data to identify documentation, coding and charging opportunities, summarizes data and prepares summary materials for discussion with clinical and finance teams. • Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists. • Work with finance to track revenue indicators and corresponding action plans. • Auditing and monitoring of defined areas.</li><li>Performs other duties as assigned.</li><li>Complies with all policies and standards.</li><li>For specific duties and responsibilities, refer to documentation provided by the department during orientation.</li><li>Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.</li></ul> <h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Qualifications</h2> Education<ul><li>Associate's Degree in health related field (Required) or</li><li>Other Accredited Program: Diploma in RN (Required)</li><li>Bachelor's Degree in health related field (Preferred)</li></ul>Work Experience<ul><li>2+ years in CDI Specialist role (Required) and</li><li>3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required) and</li><li>Experience using clinical computer systems (Required)</li></ul>Knowledge, Skills, & Abilities<ul><li>Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.). (Required proficiency)</li><li>Excellent written and verbal communication skills including presentations. (Required proficiency)</li><li>Ability to function independently and as a team player in a fast-paced environment. (Required proficiency)</li><li>Detail-oriented, and relationship building skills. (Required proficiency)</li><li>Demonstrates and has extensive knowledge of disease pathophysiology (Required proficiency)</li><li>Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.). (Required proficiency)</li></ul>Licenses and Certifications<ul><li>Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or</li><li>Registered Health Information Administration (RHIA) (Required) or</li><li>Registered Health Information Technologist (RHIT) (Required) and</li><li>Certified Clinical Documentation Specialist (CCDS) (Required) or</li><li>Clinical Documentation Improvement Practitioner (CDIP) (Required)</li></ul>Physical Demands<ul><li>Standing Occasionally</li><li>Walking Occasionally</li><li>Sitting Constantly</li><li>Lifting Rarely 20 lbs</li><li>Carrying Rarely 20 lbs</li><li>Pushing Rarely 20 lbs</li><li>Pulling Rarely 20 lbs</li><li>Climbing Rarely 20 lbs</li><li>Balancing Rarely</li><li>Stooping Rarely</li><li>Kneeling Rarely</li><li>Crouching Rarely</li><li>Crawling Rarely</li><li>Reaching Rarely</li><li>Handling Occasionally</li><li>Grasping Occasionally</li><li>Feeling Rarely</li><li>Talking Constantly</li><li>Hearing Constantly</li><li>Repetitive Motions Frequently</li><li>Eye/Hand/Foot Coordination Frequently</li></ul>Travel Requirements<ul><li>10%</li></ul> <h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Primary Location</h2>: United States-Ohio-Shaker_Heights<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Work Locations</h2>: 3605 Warrensville Center Road 3605 Warrensville Center Road Shaker Heights 44122<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Job</h2>: Nurse – Non-Direct Patient Care<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Organization</h2>: UHHS_Revenue_Cycle<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Schedule</h2>: Full-time<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Employee Status</h2>: Regular - ShiftDays<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Job Type</h2>: Standard<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Job Level</h2>: Professional<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Travel</h2>: NoRemote Work: Yes<h2 xmlns:ftl="http://www.taleo.net/ftl" xmlns:htm="http://www.w3.org/1999/xhtml" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Job Posting</h2>: Dec 12, 2025, 8:51:43 PM

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Clinical Documentation Integrity Specialist II (Remote) ($5K sign on)

Q: Is this a full-time or part-time Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) role?

This is a full-time Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) position at University Hospitals.

Q: How do I apply for the Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) position at University Hospitals?

You can apply for this Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) position by clicking the "Apply Now" button on this page, which will take you to University Hospitals's application portal.

Join University Hospitals as a mid professional working remotely from United States. Explore the role, benefits, and apply in one place.

Clinical Documentation Integrity Specialist II (Remote) ($5K sign on)

University Hospitals

Full Time

$80,000 - $120,000*

9 months ago

Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) - (25000B99)Description A Brief OverviewThe Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of…

United States

Engineering

Mid

Clinical Documentation Integrity

Medical Record Review

Coding Expertise

+2 more

Job Description

Clinical Documentation Integrity Specialist II (Remote) ($5K sign on) - (25000B99)

Description

A Brief Overview

The Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the patient complexity and resource utilization. The CDI Specialist assesses the clinical documentation through extensive review of the medical record, interacts with multiple members of the healthcare team, educates and assists the clinical areas in effective and compliant documentation. The CDI Specialist provides guidance with processes in the clinical departments to support accurate, timely and complete documentation in agreement with company policies and procedures.

What You Will Do

Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient complexity and resource utilization. Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
• Responsible and accountable for expanding CDI and coding knowledge (keeping up to date on latest research, technology, treatment modalities, etc.)
• Utilizes critical thinking/problem solving processes
• Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines
• Identifies query opportunities for record integrity
• Is proficient in query writing so that the question is easily understood by the physician
• Query writing is AHIMA compliant per practice briefs
• Escalates non-response to query by physicians immediately according to query escalation policy
• Collaborates with the coding team
• Demonstrates proficiency in reviewing increasingly complex cases.
• Demonstrates proficiency and efficiency in cross covering for other units, specialties and hospitals as assigned.
Actively engages in educating physicians and other clinical care providers regarding clinical documentation in a variety of formats including participation in clinical rounding, service line focused education sessions and one to one case specific feedback.
• Consistently provides a collaborative relationship with healthcare team providers/members
• Participates in service line rounding/touch-point routinely.
• Provides ongoing service line directed education to provider teams
Applies knowledge of health care workflows in order to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes.
• Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
• Identifies opportunity utilizing resources and follows department guidelines for processes
• Comprehends the impact of accurate clinical documentation in the medical record: accurate billing, public reporting, research data, quality metrics, provider scorecards, etc.
Meets established operational and productivity standards.
• Consistently meets productivity, quality, and ethical standards.
• Proficient and efficient use of the CDI business platform
• Serves as a mentor to other Clinical Documentation Specialists, participates in committees

Additional Responsibilities

Amendment for Inpatient Clinical Documentation Specialist • Performs review of facility inpatient encounters to ensure hospital case-mix index and severity profiles are accurate by performing timely medical record review, determination of working DRG assignment and applying clinical expertise to identify opportunities for improved or clarified documentation that accurately reflects the severity of illness and risk of mortality of the patient. Direct and timely follow-up with clinical providers to ensure requested clarification is provided. • Demonstrates proficiency in establishing and reconciling DRG processes compliant with departmental guidelines and CMS regulations. • Demonstrates proficiency in reviewing increasingly complex (SOI and ROM) cases. • Participates in service line rounding/touch-point routinely, based on facility needs. • Identifies HAC/PSI query opportunity utilizing resources and follows department guidelines for HAC/PSI query processes • Comprehends the impact of accurate clinical documentation in the medical record beyond establishing a working DRG: accurate billing, public reporting, research data, quality metrics, provider scorecards, accuracy of the UHDDS, Case Mix Index (CMI). • Demonstrates skills of high efficiency and accuracy to identify and reduce DRG downgrades/denial risks by assuring that clinical support is beyond dispute for DRG integrity, coding and billing needs
Amendment for Outpatient Clinical Documentation Specialist • Performs review of facility outpatient encounters identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges. • Coordinates with clinical departments including Coding, CDM, Finance and others to review, correct claims and identify root cause of missing charges. • Performs analysis of patient clinical and billing data to identify documentation, coding and charging opportunities, summarizes data and prepares summary materials for discussion with clinical and finance teams. • Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists. • Work with finance to track revenue indicators and corresponding action plans. • Auditing and monitoring of defined areas.
Performs other duties as assigned.
Complies with all policies and standards.
For specific duties and responsibilities, refer to documentation provided by the department during orientation.
Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Qualifications

Education

Associate's Degree in health related field (Required) or
Other Accredited Program: Diploma in RN (Required)
Bachelor's Degree in health related field (Preferred)

Work Experience

2+ years in CDI Specialist role (Required) and
3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required) and
Experience using clinical computer systems (Required)

Knowledge, Skills, & Abilities

Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.). (Required proficiency)
Excellent written and verbal communication skills including presentations. (Required proficiency)
Ability to function independently and as a team player in a fast-paced environment. (Required proficiency)
Detail-oriented, and relationship building skills. (Required proficiency)
Demonstrates and has extensive knowledge of disease pathophysiology (Required proficiency)
Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.). (Required proficiency)

Licenses and Certifications

Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or
Registered Health Information Administration (RHIA) (Required) or
Registered Health Information Technologist (RHIT) (Required) and
Certified Clinical Documentation Specialist (CCDS) (Required) or
Clinical Documentation Improvement Practitioner (CDIP) (Required)

Physical Demands

Standing Occasionally
Walking Occasionally
Sitting Constantly
Lifting Rarely 20 lbs
Carrying Rarely 20 lbs
Pushing Rarely 20 lbs
Pulling Rarely 20 lbs
Climbing Rarely 20 lbs
Balancing Rarely
Stooping Rarely
Kneeling Rarely
Crouching Rarely
Crawling Rarely
Reaching Rarely
Handling Occasionally
Grasping Occasionally
Feeling Rarely
Talking Constantly
Hearing Constantly
Repetitive Motions Frequently
Eye/Hand/Foot Coordination Frequently

Travel Requirements

Primary Location

: United States-Ohio-Shaker_Heights

Work Locations

: 3605 Warrensville Center Road 3605 Warrensville Center Road Shaker Heights 44122

Job

: Nurse – Non-Direct Patient Care

Organization

: UHHS_Revenue_Cycle

Schedule

: Full-time

Employee Status

: Regular - ShiftDays

Job Type

: Standard

Job Level

: Professional

Travel

: NoRemote Work: Yes

Job Posting

: Dec 12, 2025, 8:51:43 PM

Requirements

Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment
Direct and timely follow-up with clinical providers to ensure requested clarification is provided
Utilizes critical thinking/problem solving processes
Identifies query opportunities for record integrity
Escalates non-response to query by physicians immediately according to query escalation policy

Benefits

401k Matching
Health Insurance
Paid Time Off
Remote Work

Skills

Clinical Documentation Integrity

Medical Record Review

Coding Expertise

Query Writing

AHIMA Compliance

About AI-Estimated Salary

The salary range shown was not provided by the employer. Our AI has estimated it based on the job title, required experience, location, and industry standards (confidence: 80%). This estimate should be used as a general guide only and may not reflect the actual compensation. Always confirm salary details directly with the employer during the application process.

Ready to Apply?

Join University Hospitals today

Salary Range (AI-Estimated)*

$80,000 - $120,000

80% confidence

Posted 9 months ago

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