Clinical Documentation Specialist

About the role

The Clinical Documentation Specialist supports the University of Arkansas for Medical Sciences by ensuring that patient records are complete, accurate, and compliant with regulatory standards. Working closely with physicians, nurses, and coding staff, the specialist helps improve the quality of clinical documentation and facilitates optimal patient care.

Key responsibilities

• Review and edit inpatient and outpatient medical records for completeness, accuracy, and proper use of terminology.
• Provide real‑time feedback and education to clinicians on documentation best practices.
• Collaborate with coding and billing teams to ensure documentation supports appropriate reimbursement.
• Maintain compliance with federal, state, and institutional documentation policies.
• Participate in quality improvement initiatives related to clinical documentation.

Required profile

• Bachelor’s degree in Health Information Management, Nursing, or a related health field.
• Demonstrated experience in clinical documentation or medical record review.
• Strong knowledge of medical terminology, anatomy, and coding guidelines.
• Excellent attention to detail and ability to communicate effectively with clinical staff.

Required skills

What we offer

• Comprehensive medical, dental, and vision insurance for eligible staff and families.
• Holiday, vacation, and sick leave accrual.
• Education discount for staff and dependents (undergraduate).
• Retirement plan with up to 10 % employer match.
• Basic life insurance coverage up to $50,000.
• Career training, educational opportunities, and merchant discounts.
• On‑site concierge prescription delivery through the UAMS pharmacy.