Learn More

As an essential member of the Coding and Data Quality team, the Clinical Documentation Specialist is responsible for improving the quality, accuracy, and completeness of clinical documentation to accurately reflect patient severity of illness and risk of mortality. This role leverages strong analytical and critical thinking skills to identify documentation opportunities, assign working DRGs, and collaborate closely with physicians and multidisciplinary care teams. The Clinical Documentation Specialist plays a key role in supporting optimal reimbursement, accurate coding practices, data integrity, quality reporting, and clinical outcomes through education, documentation improvement initiatives, and effective physician engagement.

As a successful candidate, you will:

• Facilitate improvements in clinical documentation quality, completeness, and accuracy to support patient care and reimbursement outcomes.
• Analyze clinical records and identify documentation opportunities related to severity of illness, risk of mortality, and coding accuracy.
• Assign working DRGs for inpatient admissions and support appropriate code assignment.
• Collaborate with physicians, Nurse Case Managers, and multidisciplinary care teams to obtain complete and accurate clinical documentation.
• Query providers to clarify incomplete, conflicting, or ambiguous documentation using approved processes.
• Perform clinical record abstracting and data collection to support reimbursement, quality initiatives, and outcome reporting.
• Educate physicians and care teams on documentation standards, coding updates, MS-DRG changes, and coding guidelines.
• Ensure the accuracy and integrity of medical record data prior to billing and claims submission.
• Partner with Patient Accounting and coding teams to resolve reimbursement and documentation-related issues.
• Support quality management and continuous improvement initiatives through data analysis, education, and documentation integrity efforts.

Your qualifications should include:

• Associate's or Bachelor's degree in Health Information Management and/or a Certified Coding Specialist (CCS) credential.
• Minimum of two years of inpatient clinical coding experience or successful completion of a coding competency assessment.
• CCS, CDIP, or CCDS certification required.
• Familiarity with concurrent coding models strongly preferred.
• Proficiency with Encoder/Grouper technology and strong computer skills.
• Understanding of clinical documentation improvement (CDI) principles and coding compliance requirements.
• Ability to effectively communicate and collaborate with physicians and interdisciplinary teams.
• Strong analytical, critical thinking, and problem-solving skills.
• Commitment to maintaining data integrity, coding accuracy, and regulatory compliance.
• Nursing degree and/or registered nurse experience preferred.

City of Hope employees' pay is based on the following criteria: work experience, qualifications, and work location.

City of Hope is an equal opportunity employer.