Clinical Documentation Specialist
Chicago, Cook County, Illinois, 60290, USA
Listed on 2026-03-12
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Healthcare
Medical Records, Health Informatics, Healthcare Administration, Medical Billing and Coding
The Clinical Documentation Specialist is responsible for ensuring the accuracy, completeness, and compliance of clinical documentation within electronic health records (EHR) and other medical systems. This role supports healthcare providers and clinical teams by reviewing documentation, facilitating proper coding, and ensuring adherence to regulatory and compliance standards.
The Clinical Documentation Specialist collaborates closely with physicians, nurses, coding staff, and compliance teams to maintain high-quality clinical records and improve patient care outcomes.
This is a fully remote position; however, applicants must currently reside in the United States and be legally authorized to work in the U.S. Applications from individuals residing outside the United States will not be considered.
Key ResponsibilitiesReview clinical documentation for completeness, accuracy, and compliance with regulatory standards
Ensure documentation supports appropriate coding and billing requirements
Collaborate with physicians, nurses, and other clinical staff to clarify documentation gaps
Maintain knowledge of clinical terminology, coding standards (ICD-10, CPT, HCPCS), and compliance requirements
Monitor and report on documentation quality metrics
Provide feedback and education to clinical staff to improve documentation practices
Assist in audits and quality improvement initiatives related to clinical documentation
Maintain confidentiality and adhere to HIPAA regulations and organizational policies
Participate in cross-functional projects to optimize documentation workflows
Required QualificationsBachelors degree in Nursing (RN), Health Information Management, or a related healthcare field
2–5 years of experience in clinical documentation, coding, or health information management
Knowledge of medical terminology and healthcare documentation standards
Familiarity with EHR systems and clinical workflow processes
Strong attention to detail and organizational skills
Excellent written and verbal communication skills
Ability to work independently in a remote environment
Understanding of compliance, privacy, and regulatory requirements
Preferred QualificationsCertified Clinical Documentation Specialist (CCDS) credential or equivalent
Experience with ICD-10, CPT, and HCPCS coding
Previous experience in hospital, clinical, or healthcare operations environments
Familiarity with quality improvement and documentation audit processes
Knowledge of healthcare analytics and reporting tools
CompensationAnnual Salary Range: $70,000 – $95,000 USD, depending on experience, certifications, and healthcare expertise
Eligible employees may receive the following benefits:
Comprehensive medical, dental, and vision insurance
401(k) retirement plan with employer matching
Paid time off (PTO) including vacation, holidays, and sick leave
Life insurance and disability coverage
Flexible remote work environment
Professional development and certification support
Employee wellness and assistance programs
Potential performance-based bonuses
Work Authorization RequirementApplicants must meet the following requirements:
Must currently reside in the United States
Must be legally authorized to work in the United States
Applications from individuals residing outside the U.S. will not be considered
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