A Clinical Documentation Specialist is a healthcare professional who is responsible for maintaining and ensuring the accuracy of medical records. They also work towards making sure that the documentation aligns with the coding guidelines and legal requirements.
Clinical Documentation Specialists work in various healthcare institutions, including hospitals, clinics, and health departments. Their main duty is to review and verify the patients' medical records and make sure they are complete. They also ensure that these records can be easily understood and follow the required standards.
With increasing emphasis on data and records in healthcare, Clinical Documentation Specialists are in high demand. There are opportunities to work in diverse healthcare settings, with interesting roles and potential for professional growth and progression.
RN Clinical Documentation Specialist Senior-Full Time
$76K - $110K *
Transform clinical documentation integrity by leveraging your nursing expertise to ensure accuracy, quality, and compliance in healthcare records while collaborating with teams to enhance patient outc...
2 weeks ago
SUPV - CLINICAL DOCUMENTATION INTEGRITY - SAHARA LAKES (FULL-TIME)
$85K - $100K *
Champion clinical excellence by leading the CDI team to enhance documentation quality. Drive initiatives that foster operational success while implementing strategic improvements in clinical documenta...
4 weeks ago
$80K - $95K *
Optimize clinical documentation and DRG assignments through targeted validation, using advanced analytics and technology. Collaborate with coding professionals to enhance documentation quality and rei...
3 weeks ago
$74K - $96K *
Join a team that's committed to enhancing inpatient documentation accuracy and DRG assignment through targeted reviews, leveraging technology and analytics. Your expertise will significantly impact cl...
4 weeks ago
RN, Clinical Documentation Integrity Specialist
$71K - $105K *
Shape the future of healthcare documentation by collaborating with clinical teams to enhance provider documentation accuracy, ensure compliance with CMS guidelines, and improve patient outcomes throug...
5 days ago
Director, Clinical Documentation Integrity
$117K - $176K *
Lead a strategic team in enhancing Clinical Documentation Integrity, ensuring excellence in documentation, reimbursement accuracy, and compliance while collaborating with healthcare stakeholders to dr...
2 weeks ago
Manager, Clinical Documentation Integrity
$93K - $160K *
Elevate clinical documentation integrity by managing staff operations, ensuring compliance and accuracy in reporting, while collaborating with healthcare leaders to improve outcomes and optimize proce...
Today
Coding and Documentation Specialist/HIM Supervisor FT 2026-6975
$94K - $112K *
Optimize documentation accuracy and coding practices while fostering collaboration across clinical and business healthcare disciplines. Engage with physicians and coding teams to enhance patient data...
3 weeks ago
RN Educator, Clinical Documentation Integrity - Must Reside in Colorado
$85K - $132K *
Join a team that is dedicated to enhancing healthcare quality through educational strategies and clinical documentation improvements, impacting both patient care and organizations' compliance with bes...
3 weeks ago
Senior Medical Documentation Auditor
$80K - $95K *
Champion compliance and audit excellence by conducting thorough medical record audits, leading educational sessions, and providing expert guidance on documentation standards to enhance overall healthc...
2 weeks ago
Nurse Specialist, Clinical Documentation Improvement
$80K - $95K *
Join our team to enhance clinical documentation quality through collaboration, education, and continuous improvement. Engage with healthcare professionals to ensure accurate patient records and suppor...
3 weeks ago
Nurse Specialist, Clinical Documentation Improvement
$80K - $95K *
Lead initiatives to enhance clinical documentation quality by collaborating with healthcare professionals. Engage in education, support accurate records, and ensure compliance with regulations to opti...
3 weeks ago
$113K - $164K *
Join a team that shapes the future of coding excellence, providing leadership and educational oversight in coding operations while driving compliance, accuracy, and continuous improvement across our o...
3 days ago
clinical documentation manager
$87K - $162K *
Serve as a key driver of quality improvement and compliance across acute care facilities. Leverage strong leadership and analytical skills to influence departmental goals, enhance training, and suppor...
Today
Clinical Quality Auditor, Sr. Specialist - Outpatient & DRG- Remote
$79K - $105K *
Unlock potential by enhancing coding accuracy through quality assurance auditing and training. Drive clinical documentation improvement while ensuring compliance with coding guidelines and reimburseme...
2 weeks ago
Manager - RN Clinical Documentation
$80K - $95K *
Advance clinical documentation practices by managing workflows, optimizing billing processes, and leading a dedicated team to enhance revenue cycle efficiency and ensure compliance with regulations fo...
Reposted 2 weeks ago
Registered Nurse (RN) - Clinical Documentation Specialist, 40 hours/week
$79K - $138K *
Drive exceptional patient care by ensuring accurate medical documentation and compliance. Collaborate with healthcare teams to enhance medical record integrity, supporting quality patient outcomes and...
2 weeks ago
Clinical Data Quality Assurance
$75K - $90K *
Discover a rewarding role focusing on clinical data quality assurance, enhancing healthcare data reliability and accuracy. Collaborate with diverse stakeholders to resolve discrepancies and ensure hig...
Yesterday
$80K - $90K *
Lead the charge in investigating and adjusting multi-line claims, ensuring compliance with standards while providing excellent client service. This remote position involves critical decision-making an...
Today
$80K - $90K *
Join a team that's dedicated to investigating and adjusting multi-line claims, supporting clients with quality service while handling complex liability cases. This role offers growth opportunities in...
3 weeks ago
Risk Adjustment Documentation & Coding Educator
$74K - $90K *
Join a team dedicated to enhancing coding accuracy and clinical documentation through education, relationship-building, and compliance. You'll engage with providers and coding leaders while supporting...
1 week ago
$85K - $100K *
Champion evidence-based practices and enhance patient care quality. Collaborate with multidisciplinary teams to monitor, evaluate, and improve clinical outcomes while mentoring staff and managing pati...
2 weeks ago
RN Nurse Clinical Documentation Improvement Specialist
$114K *
Unlock potential by enhancing clinical documentation through expert reviews, education, and collaboration. Ensure accuracy and compliance within inpatient records while driving improvements in quality...
Yesterday
RN Nurse Clinical Documentation Improvement Specialist
$114K *
Reimagine clinical documentation practices as you enhance patient care quality through effective evaluation of medical records, ensuring accuracy, compliance, and improvement initiatives with healthca...
1 week ago
Senior Epic Clinical Documentation Analyst
$84K - $157K *
Accelerate progress at patient care delivery by overseeing Epic system implementations and configurations. Collaborate with stakeholders to analyze workflows, troubleshoot issues, and ensure complianc...
Reposted 5 days ago
What is a Clinical Documentation Specialist?
A Clinical Documentation Specialist is a healthcare professional responsible for the accuracy and completeness of medical records. They ensure these records meet coding guidelines and legal requirements.
Where can Clinical Documentation Specialists work?
Clinical Documentation Specialists work in a variety of healthcare settings such as hospitals, clinics, and health departments.
What is the average salary for Clinical Documentation Specialist jobs?
The average salary can vary depending on the location and the company. However, on Ladders, you can find Clinical Documentation Specialist jobs that pay over $100000.
What qualifications do I need to become a Clinical Documentation Specialist?
Typically, a Clinical Documentation Specialist requires a degree in health informatics or a similar field and some prior experience in a healthcare setting. Further, professional certification may enhance job prospects.