Clinical Documentation Specialist

Remote Jobs; Little Rock (AR); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health, Dental, Vision plans

Retirement match (up to 10%)

Paid time off

Education discount

Life insurance

Professional development

Merchant discounts

Prescription delivery on campus

Job summary

The Clinical Documentation Improvement Specialist at University of Arkansas for Medical Sciences will improve documentation quality to accurately reflect patient severity and resource use. You will review death records, educate care teams, and ensure correct coding and reimbursement practices across inpatient settings.

Ideal candidates are RN with active license and 4+ years of inpatient experience, preferably with CCDS or CCDS readiness, and strong collaboration skills within a hospital team.

Qualifications

• RN with active license and 4+ years inpatient experience in ED/ICU/Med-Surg.
• CCDS within 6 months of hire; CCDS preferred.
• Strong knowledge of ICD-10 coding guidelines.
• Excellent collaboration and communication with care teams.

Responsibilities

• Improve quality and completeness of clinical documentation to reflect severity of illness and resource use.
• Review death records to ensure accurate risk of mortality and severity scores.
• Educate providers on admission types and documentation standards.
• Collaborate with physicians, nursing, coding staff to ensure accurate coding and reimbursement.
• Develop and deliver education on clinical documentation improvement and regulatory requirements.

Skills

RN license

Inpatient clinical experience 4+ years

CCDS/CCDS within 6 months

Strong communication

Education

BSN or higher

CCDS certification preferred

Tools

Coding knowledge (ICD-10)

CMS/NCHS ICD-10 guidelines

Job description

Current University of Arkansas System employees, including student employees and graduate assistants, need to log in to Workday via MyApps.Microsoft.com, then access Find Jobs from the Workday search bar to view and apply for open positions. Students at University of Arkansas System will also view open positions and apply within Workday by searching for "Find Jobs for Students".

All Job Postings will close at 12:01 a.m. CT on the specified Closing Date (if designated).

If you close the browser or exit your application prior to submitting, the application process will be saved as a draft. You will be able to access and complete the application through "My Draft Applications" located on your Candidate Home page.

Closing Date

08/25/2026

Type of Position

Professional Staff - Project/Program Administration

Job Type

Regular

Work Shift

Day Shift (United States of America)

Sponsorship Available

No

Institution Name

University of Arkansas for Medical Sciences

The University of Arkansas for Medical Sciences (UAMS) has a unique combination of education, research, and clinical programs that encourages and supports teamwork and diversity. We champion being a collaborative health care organization, focused on improving patient care and the lives of Arkansans.

UAMS offers amazing benefits and perks

• Health: Medical, Dental and Vision plans available for qualifying staff and family
• Holiday, Vacation and Sick Leave
• Education discount for staff and dependents (undergraduate only)
• Retirement: Up to 10% matched contribution from UAMS
• Basic Life Insurance up to $50,000
• Career Training and Educational Opportunities
• Merchant Discounts
• Concierge prescription delivery on the main campus when using UAMS pharmacy

The University of Arkansas is an equal opportunity institution. The University does not discriminate in its education programs or activities (including in admission and employment) on the basis of any category or status protected by law, including age, race, color, national origin, disability, religion, protected veteran status, military service, genetic information, sex, sexual preference, or pregnancy. Questions or concerns about the application of Title IX, which prohibits discrimination on the basis of sex, may be sent to the University's Title IX Coordinator and to the U.S. Department of Education Office for Civil Rights.

Persons must have proof of legal authority to work in the United States on the first day of employment.

All application information is subject to public disclosure under the Arkansas Freedom of Information Act.

Department

FIN | CORE CDI Clinical Doc Team

Summary of Job Duties

The Clinical Documentation Improvement Specialist is responsible for improving overall quality and completeness of clinical documentation to ensure that the information in the medical record accurately reflects the patient's severity of illness, clinical needs, and utilization of resources. This position is responsible for reviewing death medical records to ensure the severity of illness and risk of mortality has been captured at the highest level. This position works with the providers of care to capture the clinical care in a code format for reimbursement and to ensure UAMS has the correct case mix. Reviews all admission types to the hospital to ensure of severity is captured and then educates the providers of care on admission types.

Qualifications

Minimum Qualifications

• Registered Nurse (RN) with current license plus 4 years inpatient clinical experience in Emergency, Critical Care, or Medical/Surgical area with experience in Quality, Case Management, Clinical Audit, or Data Abstraction OR Coding professional with CCS certification and 6 years of inpatient coding experience with documented education in anatomy/physiology and pharmacology.
• CCDS is required within 6 months of hire

Preferred Qualifications

• Current CCDS

Additional Information

• Applies extensive clinical knowledge to read and analyze health record documentation, identifying all significant diagnoses, treatment, and procedures impacting acuity level and resources consumed throughout the current hospitalization; applies knowledge of disease processes, surgical procedures, UHDDS definitions, and the CMS/NCHS ICD-10 Official Coding Guidelines for Coding and Reporting to assign non-indexed terms to the appropriate class within the ICD-10 coding classification system.
• Reviews all death medical records and works with Vizient calculator to ensure risk of mortality and severity of illness scores are correct. Reviews all admission types to the hospital to ensure severity is captured.
• Interacts directly with physicians, nursing staff, other patient caregivers, coding staff, and other members of the health care team to facilitate clarification of clinical documentation and transfer of knowledge related to accurate documentation, coding, and reimbursement practices; ensures that documentation is clear, concise, and written in diagnostic terms reflecting the highest level of specificity.
• Develops and facilitates education related to clinical documentation improvement, coding guidelines, and regulatory requirements to all members of the healthcare team through one-on-one communication and classroom or large group presentations throughout the year as assigned.
• Performs other duties as assigned.

Salary Information

Commensurate with education and experience

Required Documents to Apply

List of three Professional References (name, email, business title), Resume

Optional Documents

Proof of Veteran Status

Pre-employment Screening Requirements

Criminal Background Check

Constant Physical Activity

Manipulate items with fingers, including keyboarding, Repetitive Motion, Sitting

Frequent Physical Activity

Hearing, Talking

Occasional Physical Activity

Crawling, Crouching, Kneeling, Lifting, Pulling, Pushing, Standing, Walking

Benefits Eligible

Yes