Jefferson Health
Clinical Documentation Improvement Specialist
Northeast Philadelphia, PA · Full-time · Posted Aug 5, 2026
- Experience
- Preferred: 2–3 years of Clinical Documentation Improvement experience or 5 years of Coding experience; alternatively, 5 years of Critical Care/Emergency medicine or Medical Surgical experience. MD/DO candidates with 2 years as a concurrent or retrospective coder or documentation specialist in an inpatient acute care facility using the United States IPPS system will be considered.
- Education
- Bachelor of Science in Nursing; Bachelor of Science in Health Information Management or related field; or certification, associate, or bachelor’s degree in another healthcare-related field with the stated experience.
About the job
Reviews inpatient medical records and works with providers and coding staff to improve documentation accuracy, completeness, compliance, and clinical outcome reporting.
What you'll do
- Review records for documentation and regulatory completeness; identify deficiencies and issue compliant queries.
- Educate and collaborate with physicians, other providers, and coding staff to ensure records accurately reflect diagnoses and care.
- Track review activity and trends, maintain productivity, and contribute to department improvement.
What they ask for
- Bachelor of Science in Nursing; Bachelor of Science in Health Information Management or related field; or a certification, associate, or bachelor’s degree in another healthcare-related field with the stated experience.
- Familiarity with computers and Microsoft Office applications.
- Ability to work independently with minimal supervision.
- Ability to read and communicate in English.
Nice to have
- CCDS or CDIP certification; RN/BSN preferred. CCDS required within 6 months of hire for eligible candidates.
- Working knowledge of Medicare reimbursement and coding structures; stated clinical documentation, coding, or clinical-care experience.
Tools
Epic EHR, 3M DRG, MS Office, CDI software tracking tool
Model-written summary · the original posting is authoritative