Is the Clinical Documentation Specialist, Professional Fee (Remote) position at University Hospitals fully remote?

Yes, this Clinical Documentation Specialist, Professional Fee (Remote) position at University Hospitals is a remote position. The role is available for candidates in United States.

Is this a full-time or part-time Clinical Documentation Specialist, Professional Fee (Remote) role?

This is a full-time Clinical Documentation Specialist, Professional Fee (Remote) position at University Hospitals.

What are the main requirements for the Clinical Documentation Specialist, Professional Fee (Remote) role?

Key requirements include: Clinical documentation expertise, Strong analytical and problem-solving skills, Ability to work independently and collaboratively, and more.

What benefits does University Hospitals offer for this position?

University Hospitals offers the following benefits: Health Insurance, Dental Insurance, Vision Insurance, 401k Matching, Employee Assistance Program, Flexible Hours, Paid Time Off, Sick Leave.

Clinical Documentation Specialist, Professional Fee (Remote) at University Hospitals

United States

Clinical Documentation Specialist, Professional Fee (Remote) - (25000B65)<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 Professional Fee Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels thereby supporting the provider's efforts and their professional fee billing. The CDS primarily assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity. The Professional Fee CDS will focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs), which directly impact the patient risk adjusted profile (RAF score) calculated by the associated risk plans. They will also assist with highlighting opportunities based on the provider's medical decision making to appropriately reflect the level of service provided for patient care.The Professional Fee CDS will be responsible for completing pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices, in adherence to compliance standards set by governing entities such as CMS, AHA, etc.• Pre-visit reviews are intended to identify documentation opportunities for the provider to recapture previously documented HCCs diagnoses, or new suspect conditions not previously captured that are identified by the CDS's comprehensive chart reviews. These efforts assist in establishing accurate risk profiles and related health care costs• Post-claim reviews focus on E/M encounters and highlight opportunities based on a provider's medical decision making and the patient's acuity to support appropriate and accurate E/M level assignments as well as any HCCs identified• The Professional Fee CDS will also coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation based on findings from pre-visit and post-claim reviewsWhat You Will Do<ul><li>Coordination with Professional Fee CDI Program leadership and colleagues. Fosters teamwork and utilizes strong team building measures</li><li>Performs pre-visit chart reviews to assist in highlighting relevant documentation and diagnoses in compliance with governing policies and industry guidelines. Applies a “clinical detective” mindset to identify new HCC diagnosis capture opportunities based on appropriate clinical indicators for the patient. Also performs post-claim reviews focused on appropriate E/M level assignments and any opportunities related to level of service and HCCs.</li><li>Uses performance and outcome data from third-party support or other sources to identify high priority providers</li><li>Creates specialty-specific education on relevant topics as identified in data analytics and from clinical encounter reviews and post-claim education chart reviews</li><li>Develops and maintains a systematic education schedule and approach for providers in the hospital and clinic/office setting including but not limited to complete documentation, appropriate diagnosis code selection, E/M level assignments and updates to coding guidelines.</li><li>Delivers ongoing feedback and education to communicate importance of complete documentation and key concepts during regular clinic or provider meetings or on individual basis, as needed</li><li>Upholds working knowledge and stays current on latest CMS and industry guidelines, with specific understanding of HCCs and implications for documentation</li><li>Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines</li></ul>Additional Responsibilities<ul><li>Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission. Demonstrates knowledge of and follows departmental and hospital policies and physician office procedures</li><li>Seeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications, as required.</li><li>Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other personnel</li><li>Serves on department and/or institutional committees as requested</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>High School Equivalent / GED (Required)</li><li>Associate's Degree (Preferred)</li></ul>Work Experience<ul><li>3+ years Coding and/or clinical documentation integrity (Required)</li></ul>Knowledge, Skills, & Abilities<ul><li>Extensive clinical knowledge and understanding of pathophysiology (Required proficiency)</li><li>Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record (Required proficiency)</li><li>Excellent written and verbal communication skills (Required proficiency)</li><li>Strong project management skills (Required proficiency)</li><li>Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization (Required proficiency)</li><li>Ability to work independently in a time-oriented environment (Required proficiency)</li><li>Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency)</li><li>Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency)</li><li>Ability to build education material that is meaningful for providers and team members (Required proficiency)</li><li>Strong problem solving and investigative skills (Required proficiency)</li></ul>Licenses and Certifications<ul><li>Certified Coding Specialist (CCS) (Required) or</li><li>Certified Professional Coder (CPC) or CRC, or other coding or CDI credential (Required)</li><li>Registered Nurse (RN), Ohio and/or Multi State Compact License (Preferred) or</li><li>Licensed Practical Nurse (LPN), Ohio and/or Multi State Compact License (Preferred)</li></ul>Physical Demands<ul><li>Standing Occasionally</li><li>Walking Occasionally</li><li>Sitting Constantly</li><li>Lifting Rarely up to 20 lbs</li><li>Carrying Rarely up to 20 lbs</li><li>Pushing Rarely up to 20 lbs</li><li>Pulling Rarely up to 20 lbs</li><li>Climbing Rarely up to 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-Cleveland<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>: 11100 Euclid Avenue 11100 Euclid Avenue Cleveland 44106<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>: Administrative Support<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_Coding<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>: Yes, 10 % of the TimeRemote 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, 8:49:50 PM

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Remote Opportunity

Clinical Documentation Specialist, Professional Fee (Remote)

Q: How do I apply for the Clinical Documentation Specialist, Professional Fee (Remote) position at University Hospitals?

You can apply for this Clinical Documentation Specialist, Professional Fee (Remote) 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 senior professional working remotely from United States. Explore the role, benefits, and apply in one place.

Clinical Documentation Specialist, Professional Fee (Remote)

University Hospitals

Full Time

$120,000 - $180,000*

9 months ago

Clinical Documentation Specialist, Professional Fee (Remote) - (25000B65)Description A Brief OverviewThe Professional Fee Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient…

United States

Data

Senior

Compliance

Billing

Clinical Documentation

+5 more

Job Description

Clinical Documentation Specialist, Professional Fee (Remote) - (25000B65)

Description

A Brief Overview

The Professional Fee Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels thereby supporting the provider's efforts and their professional fee billing. The CDS primarily assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity. The Professional Fee CDS will focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs), which directly impact the patient risk adjusted profile (RAF score) calculated by the associated risk plans. They will also assist with highlighting opportunities based on the provider's medical decision making to appropriately reflect the level of service provided for patient care.The Professional Fee CDS will be responsible for completing pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices, in adherence to compliance standards set by governing entities such as CMS, AHA, etc.• Pre-visit reviews are intended to identify documentation opportunities for the provider to recapture previously documented HCCs diagnoses, or new suspect conditions not previously captured that are identified by the CDS's comprehensive chart reviews. These efforts assist in establishing accurate risk profiles and related health care costs• Post-claim reviews focus on E/M encounters and highlight opportunities based on a provider's medical decision making and the patient's acuity to support appropriate and accurate E/M level assignments as well as any HCCs identified• The Professional Fee CDS will also coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation based on findings from pre-visit and post-claim reviews

What You Will Do

Coordination with Professional Fee CDI Program leadership and colleagues. Fosters teamwork and utilizes strong team building measures
Performs pre-visit chart reviews to assist in highlighting relevant documentation and diagnoses in compliance with governing policies and industry guidelines. Applies a “clinical detective” mindset to identify new HCC diagnosis capture opportunities based on appropriate clinical indicators for the patient. Also performs post-claim reviews focused on appropriate E/M level assignments and any opportunities related to level of service and HCCs.
Uses performance and outcome data from third-party support or other sources to identify high priority providers
Creates specialty-specific education on relevant topics as identified in data analytics and from clinical encounter reviews and post-claim education chart reviews
Develops and maintains a systematic education schedule and approach for providers in the hospital and clinic/office setting including but not limited to complete documentation, appropriate diagnosis code selection, E/M level assignments and updates to coding guidelines.
Delivers ongoing feedback and education to communicate importance of complete documentation and key concepts during regular clinic or provider meetings or on individual basis, as needed
Upholds working knowledge and stays current on latest CMS and industry guidelines, with specific understanding of HCCs and implications for documentation
Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines

Additional Responsibilities

Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission. Demonstrates knowledge of and follows departmental and hospital policies and physician office procedures
Seeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications, as required.
Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other personnel
Serves on department and/or institutional committees as requested
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

High School Equivalent / GED (Required)
Associate's Degree (Preferred)

Work Experience

3+ years Coding and/or clinical documentation integrity (Required)

Knowledge, Skills, & Abilities

Extensive clinical knowledge and understanding of pathophysiology (Required proficiency)
Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record (Required proficiency)
Excellent written and verbal communication skills (Required proficiency)
Strong project management skills (Required proficiency)
Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization (Required proficiency)
Ability to work independently in a time-oriented environment (Required proficiency)
Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency)
Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency)
Ability to build education material that is meaningful for providers and team members (Required proficiency)
Strong problem solving and investigative skills (Required proficiency)

Licenses and Certifications

Certified Coding Specialist (CCS) (Required) or
Certified Professional Coder (CPC) or CRC, or other coding or CDI credential (Required)
Registered Nurse (RN), Ohio and/or Multi State Compact License (Preferred) or
Licensed Practical Nurse (LPN), Ohio and/or Multi State Compact License (Preferred)

Physical Demands

Standing Occasionally
Walking Occasionally
Sitting Constantly
Lifting Rarely up to 20 lbs
Carrying Rarely up to 20 lbs
Pushing Rarely up to 20 lbs
Pulling Rarely up to 20 lbs
Climbing Rarely up to 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-Cleveland

Work Locations

: 11100 Euclid Avenue 11100 Euclid Avenue Cleveland 44106

Job

: Administrative Support

Organization

: UHHS_Coding

Schedule

: Full-time

Employee Status

: Regular - ShiftDays

Job Type

: Standard

Job Level

: Professional

Travel

: Yes, 10 % of the TimeRemote Work: Yes

Job Posting

: Dec 12, 2025, 8:49:50 PM

Requirements

Clinical documentation expertise
Strong analytical and problem-solving skills
Ability to work independently and collaboratively
Excellent communication and interpersonal skills
Proficiency in coding and billing systems
Knowledge of compliance regulations and standards
Ability to analyze and interpret data
Strong attention to detail and organizational skills

Benefits

Health Insurance
Dental Insurance
Vision Insurance
401k Matching
Employee Assistance Program
Flexible Hours
Paid Time Off
Sick Leave

Skills

Compliance

Billing

Clinical Documentation

CMS

Coding

Hierarchical Condition Categories

Risk Adjusted Profile

AHA

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)*

$120,000 - $180,000

80% confidence

Posted 9 months ago

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