Clinical Documentation Improvement Specialist

Orlando Health, Inc.; Orlando (FL); On-site; USD 75,000 - 105,000; Full time

Job summary

Orlando Health, Inc. is seeking a Clinical Documentation Improvement Specialist to provide concurrent review of medical records with a clinical lens.

The role focuses on identifying missing or understated diagnoses or procedures to ensure accurate reflection of patient acuity and level of care. The position requires collaboration with physicians and hospital teams, effective querying, and education to improve documentation quality during routine physician meetings and across departments.

Qualifications

• Must hold a medical degree or an RN license from outside Florida.
• Minimum of three years clinical hospital experience with strong knowledge of pathology/physiology.
• Excellent written and verbal communication skills and concise documentation.

Responsibilities

• Conducts initial and follow-up concurrent reviews to clarify documentation for accurate acuity and level of care.
• Coordinates with coding/HIM/UR and other departments to reflect patient acuity and care level.
• Performs thorough chart reviews to identify comorbidities/complications and documents them in the CDS worksheet.

Skills

Excellent communication skills

Clinical documentation expertise

Querying & physician education

Education

Graduate from an approved school of medicine

RN license (out of state Florida)

Job description

Orlando Health, Inc. is seeking a Clinical Documentation Improvement Specialist to provide concurrent review of medical records with a clinical lens.

The role focuses on identifying missing or understated diagnoses or procedures to ensure accurate reflection of patient acuity and level of care. The position requires collaboration with physicians and hospital teams, effective querying, and education to improve documentation quality during routine physician meetings and across departments.