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Clinical Documentation Improvement Jobs (NOW HIRING)

Gbmc

Clinical Documentation Improvement Nurse

Pavilion, NY · On-site

$32.75 - $44/hr

GBMC Health Partners is looking for a Clinical Documentation Improvement Nurse/Nurse Coder to join our Primary Care group. The best candidate will be a clinically experienced nurse coder who is EMR ...

R1

Clinical Documentation Improvement Specialist

$48K - $81K/yr

As our Clinical Documentation Improvement (CDI) Specialist, you will use clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical ...

Gbmc

$33.25 - $44.75/hr

GBMC Health Partners is looking for a Clinical Documentation Improvement Nurse/Nurse Coder to join our Primary Care group. The best candidate will be a clinically experienced nurse coder who is EMR ...

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Clinical Documentation Improvement information

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$39.5K

$108.4K

$163K

How much do clinical documentation improvement jobs pay per year?

As of Aug 4, 2026, the average yearly pay for clinical documentation improvement in the United States is $108,414.00, according to ZipRecruiter salary data. Most workers in this role earn between $82,500.00 and $146,500.00 per year, depending on experience, location, and employer.

What does a clinical documentation improvement specialist do?

A clinical documentation improvement (CDI) specialist reviews and analyzes patient medical records to ensure accurate, complete, and compliant documentation. They collaborate with healthcare providers to clarify diagnoses and procedures, which supports proper coding, billing, and quality reporting. CDI specialists often use electronic health record systems and may hold certifications like CCDS to perform their duties effectively.

How to get into clinical documentation improvement?

To enter clinical documentation improvement, candidates typically need a background in healthcare, such as nursing, health information management, or medical coding, along with strong knowledge of medical terminology and coding systems like ICD-10. Gaining certification, such as Certified Clinical Documentation Specialist (CCDS), can enhance job prospects, and experience with electronic health records (EHR) systems is often required. Developing strong communication and analytical skills is also important for success in this field.

How does a clinical documentation improvement specialist typically collaborate with physicians and other healthcare team members?

A Clinical Documentation Improvement (CDI) specialist works closely with physicians, nurses, and coding professionals to ensure that patient records accurately reflect the care provided. They frequently review medical charts, query physicians for clarification on documentation, and provide education on best practices for thorough and compliant record-keeping. Effective communication and relationship-building skills are essential, as CDI specialists often serve as a bridge between clinical and coding teams. This collaborative environment helps improve patient care quality, supports accurate coding, and ensures proper reimbursement for healthcare services.

What is clinical documentation improvement?

Clinical Documentation Improvement (CDI) refers to the process of ensuring that healthcare records accurately and thoroughly reflect a patient’s diagnoses, treatments, and overall care. The goal of CDI is to improve the quality of clinical documentation so that it clearly supports the services provided, enhances patient care, and ensures compliance with regulations and reimbursement requirements. CDI professionals often work with physicians, nurses, and medical coders to clarify clinical information in the medical record. Effective CDI helps reduce errors, supports accurate coding, and can positively impact hospital revenue and patient outcomes.

What is the difference between Clinical Documentation Improvement vs Medical Records Technician?

AspectClinical Documentation ImprovementMedical Records Technician
CertificationsCCDS, CCDS-O, RHITRHIT, RHIA
Work EnvironmentHospitals, clinics, health systemsMedical record departments, healthcare facilities
Primary FocusEnhancing clinical documentation accuracy and completenessOrganizing, coding, and maintaining medical records
Industry UsageWidely used in clinical documentation and coding improvementCommon in health information management

Clinical Documentation Improvement specialists focus on improving the accuracy and completeness of clinical records to support quality care and billing, while Medical Records Technicians organize and maintain patient records. Both roles are essential in healthcare but serve different functions within health information management.

What are the key skills and qualifications needed to thrive as a clinical documentation improvement specialist?

To thrive as a Clinical Documentation Improvement (CDI) Specialist, you need a background in healthcare or nursing, strong knowledge of medical terminology, coding, and clinical documentation standards, often supported by credentials such as RN, RHIA, RHIT, or CCDS/CCDS-O certification. Familiarity with electronic health records (EHRs), clinical coding systems (like ICD-10-CM/PCS), and CDI software tools is essential. Excellent analytical skills, attention to detail, and clear communication are vital soft skills for effectively collaborating with providers and ensuring documentation accuracy. These skills are crucial for improving the quality and completeness of clinical documentation, optimizing reimbursement, and supporting patient care outcomes.
More about Clinical Documentation Improvement jobs
What cities are hiring for Clinical Documentation Improvement jobs? Cities with the most Clinical Documentation Improvement job openings:
What are the most commonly searched types of Clinical Documentation Improvement jobs? The most popular types of Clinical Documentation Improvement jobs are:
What states have the most Clinical Documentation Improvement jobs? States with the most job openings for Clinical Documentation Improvement jobs include:
What job categories do people searching Clinical Documentation Improvement jobs look for? The top searched job categories for Clinical Documentation Improvement jobs are:
Clinical Documentation Improvement jobs near you
Infographic showing various Clinical Documentation Improvement job openings in the United States as of July 2026, with employment types broken down into 2% As Needed, 73% Full Time, 17% Part Time, and 8% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution, with an average salary of $108,414 per year, or $52.1 per hour.

Manager, Clinical Documentation Improvement

University of Iowa Hospitals & Clinics

Iowa City, IA • On-site

$34 - $45.75/hr

Full-time

Medical, Dental, Life, Retirement, PTO

Re-posted 8 hours ago

University Of Iowa Health Care rating

7.4

Company rating: 7.4 out of 10

Based on 62 frontline employees who took The Breakroom Quiz

266th of 887 rated healthcare providers

Job description

Description
The Office of Clinical Documentation Improvement (CDI) at UI Health Care has an opening for a full-time CDI Manager. The CDI Manager provides leadership, direction, and oversight for clinical documentation improvement and education system-wide, to ensure complete, accurate, compliant documentation that reflects patient acuity, supports quality outcomes, and enables appropriate reimbursement. The role leads, develops, and mentors the CDI Specialist team; designs and delivers clinical care provider and staff education (including residents and new providers); partners closely with Health Information Management/Coding, Quality, Analytics, Physician Advisors, and Clinical Departments; and drives process improvement and operational consistency across the enterprise.
Job Duties Include (but are not limited to) :
Apply Process Improvement, Quality Engineering, and Management Engineering Concepts and Methodologies :
  • Coordinates documentation improvement & coding audits, providing physician documentation improvement education at the department level. This individual will be required to make decisions regarding documentation for accurate ICD-10-CM/ICD-10-CM-PCS code assignment and quality related challenges.
  • Accountable for CDI nursing and department level successes as demonstrated through various indices which include but not limited to accurate Severity of Illness (SOI) / Risk of Mortality (ROM) capture rates, Complicating or Comorbid Condition (CC) / Major Complicating or Comorbid Condition (MCC) capture rates, Case Mix Index (CMI) analysis, physician query- response rates, and tracking financial variances, while providing guidance, coaching, and counseling to staff to assure outcomes and goals are achieved.
  • Work with program leadership to plan, develop, and implement clinical documentation education programs for clinical care providers, staff, the CDI Specialist team, including resident and new provider orientation, and onboarding for CDI Specialists and patient care teams.
  • Institutes strategies that facilitate effective collaboration between the Director, Clinical Documentation Improvement, Director/Manager of Health Information Management, Administration, and other applicable departments as it relates to clinical documentation improvement.
  • Maintains and shares expertise with MS-DRG/APR-DRG's and Inpatient Prospective Payment System (IPPS), CMS guidelines and Official Coding Guidelines.
  • Works closely with Health Information Management, Clinical Documentation Specialists and the Quality Improvement Program to successfully identify, review and develop education on patient safety indicators, hospital acquired conditions and other quality driven measures.
  • Assist to maintain positive relationships with other departments and University colleges to facilitate collaboration and achievement of department, hospital, and UI Health Care goals.
  • Represents the CDI Director on hospital and UI Health Care subcommittees; chairs committees as requested.
  • Represents the UI Health Care on various internal and external committees and associations as requested by leadership.
  • Works with CDI physician advisors to ensure clear understanding of their role and improve ongoing quality improvement for CDI.

Quality Assurance and Compliance :
  • Performs routine audits of documentation queries to identify knowledge gaps and improve the accuracy of quality related documentation, capture, and query processes.
  • Evaluates regulatory changes related to quality measures and educates staff appropriately.
  • Knowledgeable of legal issues involved in patient care information and exercises considerable judgment relative to HIPAA issues and compliance, including AHIMA query practices.
  • Collaborates with the inpatient coding team and their leadership to ensure adherence to established processes, providing second level quality reviews when necessary.
  • Works closely with Physician Advisor(s)/Quality Leadership/CDI Director on escalated cases to ensure that the appropriate documentation is added to the medical record, collaborating with the inpatient Coding team and Clinical Informatics team and their leadership to ensure adherence to established processes, and providing second level reviews when necessary.
  • Evaluates regulatory changes and educates staff appropriately.

Training/Education :
  • Creates and implements consistent training and development for nursing staff, physicians and mid-level practitioners that address documentation issues and variances related to quality metrics and measures.
  • Teaches and mentors other Clinical Department Specialists on clinical documentation improvement principles and concepts, serving as a resource person to key stakeholders across the organization.
  • Leads CDI onboarding program to ensure efficient and complete education and development of clinical documentation specialists.
  • Maintains a climate of learning that promotes educational experiences for all levels of staff.
  • Assists with implementation of system and process changes, including ongoing Clinical Documentation Improvement staff training.

Leadership/Supervision :
  • Provides daily oversight and supervision of CDI Specialists/RNs.
  • Promotes department and organizational policy compliance and development with CDI Director.
  • Leads quarterly review meetings with individual CDI nurses and CDI Director.
  • Has regular, reliable, predictable attendance in the performance of essential functions while meeting or exceeding expected timelines on performance level as it relates to personnel, and reporting responsibilities.
  • Acts as delegate for Director when necessary

Human Resources Administration :
  • Hires, develops, and manages the performance of staff; assures staff are compliant with UI policies and procedures.
  • Develops and implements policies and practices of a culture that supports staff engagement.
  • Holds employees accountable for high performance and high engagement culture by sharing data, articulating expectations, monitoring performance, and providing feedback consistency across areas of responsibility.
  • Identifies and provides opportunities for the staff to develop knowledge, skills, and abilities needed to contribute to the success of the department.
  • Provides actionable quality-driven feedback for leadership and CDI specialist that allows consistent accountability supporting high performance and a high engagement culture, by articulating expectations, monitoring performance, and providing feedback consistency across areas of responsibility.
  • Assists with compliant record keeping and tracking relative to staff education.
  • Provides back up as a mentor/resource to the CDI nursing team, as needed.

To receive a copy of the full job description, you may contact heidi-bodensteiner@uiowa.edu
Percent of Time: 100% (full-time)
Work schedule: Some flexibility between the hours of 7:00 AM and 5:00 PM, Monday through Friday.
Location: This position is eligible to participate in partial remote work (working 2 - 3 days onsite per week) after the initial training and onboarding has been completed. Initial onboarding and training will be completed at the Healthcare Support Services Building (HSSB), located at 3231 Ridgeway Drive in Coralville, IA 52241. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually and must comply with the remote work program and related policies and the employee travel policy when working at a remote location .
Salary level 5B. Starting salary will be based on applicant qualifications and related experience.To view the full pay range for salary level 5B: P&S Pay Structures (Future) | University Human Resources - The University of Iowa .
Benefits Highlights: Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans. Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits .
Qualifications
Required:
  • A Baccalaureate degree or master's degree in nursing.
  • License to practice nursing in Iowa.
  • A minimum of two (2) years of recent work experience as a Clinical Documentation Improvement Specialist with at least three (3) years of clinical experience at an academic medical center.
  • At least one (1) year of managerial or supervisory experience, ELA acceptable
  • Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required.
  • A broad knowledge of the disease process, normal/abnormal findings, and reasonable course of treatment, quality measures, and risk management issues is essential.
  • Healthcare education experience with a strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payers preferred.
  • Extensive knowledge of CDI related quality measures, including AHRQ measures and AHIMA query practice guidelines, knowledge of coding structures/national coding guidelines and related appropriate chart documentation.
  • Demonstrated competency in teaching/learning process, organizational skills and computer literacy required, including proficiency with computer software applications utilized within the CDI programs (i.e. Excel, Word, PowerPoint, 3M 360)
  • Excellent professional demeanor and communication skills
  • Excellent people skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication, including presentation and training skills.
  • Excellent organizational, time management and critical thinking skills
  • Currently holds Clinical Documentation certification OR obtains certification within one (1) year, i.e.:
    • Certified Clinical Documentation Specialist (CCDS), or
    • Certified Documentation Improvement Practitioner (CDIP)
  • Electronic Medical Records experience (EPIC preferred).
  • Experience with performance improvement methodologies
  • Experience with data mining and/or data analytics

Desirable:
  • Demonstrated knowledge of healthcare outcomes and performance improvement initiatives/techniques.
  • Current coding certification (CPC, CCS, RHIA/RHIT) or additional outpatient CDI certification (CCDS-O)
  • Experience with hospital quality/safety metrics.
  • Experience working at large academic medical centers.
  • Holds a quality related certification.

Application Process:
  • To be considered for an interview, applicants must upload a current resume and a cover letter that clearly addresses how they meet the listed required and desired qualifications of this position.
  • Job openings are posted for a minimum of 7 calendar days. This job may be removed from posting and filled any time after the minimum posting period has ended.
  • Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check.
  • Professional references will be requested at a later step in the recruitment process.
  • This position is not eligible for University of Iowa sponsorship for employment authorization.
  • For questions, contact Heidi Bodensteiner at heidi-bodensteiner@uiowa.edu .

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