Clinical Documentation Specialist Jobs

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.

Job Description and Duties

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.

Career Opportunities

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.

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$95K *

Lead the charge in ensuring coding accuracy through comprehensive audits of Inpatient DRG claims. Leverage your expertise to validate clinical documentation and improve billing processes while meeting...

US-AnywhereRemote

4 days ago

  •   5 - 7 years exp.  •   Healthcare

$165K - $214K *

Grow your leadership skills while enhancing clinical documentation quality. Oversee reviews, drive compliance, and foster team collaboration to improve patient care and operational excellence across c...

Today

  •   5 - 7 years exp.  •   Healthcare

$79K - $118K *

Elevate clinical documentation quality by evaluating patient records and collaborating with healthcare teams. Ensure compliance with regulations while fostering educational opportunities for improveme...

Today

  •   5 - 7 years exp.  •   Healthcare

$66K - $98K *

Advance your career by managing medical coding for complex patient care, ensuring accurate coding for diagnoses and procedures. Contribute significantly to hospital operations with your expertise in c...

1 week ago

  •   Less than 5 years exp.  •   Healthcare

$75K - $90K *

Shape the future of healthcare documentation by collaborating with teams to enhance the quality and accuracy of clinical records, conducting second-level reviews, and driving compliance with documenta...

5 days ago

  •   Less than 5 years exp.  •   Hospitals & Medical Centers

$90K - $151K *

Engage with cross-functional teams to enhance clinical data systems, oversee eCRF development, and streamline EDC workflows while ensuring data quality, compliance, and the effective use of AI technol...

US-AnywhereRemote

Today

  •   Less than 5 years exp.  •   Pharmaceuticals & Biotech

$83K - $112K *

Develop your career by leading the Clinical Data Section focused on coding, data analysis, and compliance. This role oversees financial, educational, and operational initiatives while ensuring adheren...

2 weeks ago

  •   Less than 5 years exp.  •   Healthcare

$110K - $130K *

Empower healthcare outcomes by configuring and optimizing Epic ClinDoc workflows for inpatient nursing. Collaborate across teams to enhance documentation processes, ensuring compliance and support for...

Reposted 3 weeks ago

  •   Less than 5 years exp.  •   Hospitals & Medical Centers

$81K - $129K *

Lead the charge in operational oversight of HIMS coding data quality, guiding coder education activities to ensure compliance, accuracy, and continuous improvement in data management across acute care...

US-AnywhereRemote

Reposted 3 weeks ago

  •   5 - 7 years exp.  •   Hospitals & Medical Centers

$110K - $130K *

Engage in strategic leadership for clinical documentation integrity and post-discharge review. Drive initiatives that enhance quality outcomes, compliance, and reimbursement accuracy while fostering c...

Yesterday

  •   5 - 7 years exp.  •   Healthcare

$68K - $103K *

Unlock your potential by joining our team, leveraging your HIM expertise to interpret clinical data, ensuring compliance with national coding standards, and enhancing healthcare quality through data a...

Toronto, ONIn-Person

1 week ago

  •   Less than 5 years exp.  •   Healthcare

$80K - $100K *

Transform healthcare compliance by conducting thorough audits, providing education, and collaborating with stakeholders. This role ensures coding accuracy, regulatory adherence, and enhances revenue i...

1 week ago

  •   Less than 5 years exp.  •   Healthcare

$139K - $179K *

Lead and enhance compliance initiatives by managing audits, ensuring adherence to regulations, and fostering a culture of continuous improvement in documentation and coding practices within a collabor...

Reposted 2 weeks ago

  •   5 - 7 years exp.  •   Healthcare

$72K - $90K *

Enhance documentation practices by reviewing clinical records in the Emergency Department. Collaborate with healthcare teams to ensure compliance with coding standards, improve accuracy, and optimize...

2 weeks ago

  •   Less than 5 years exp.  •   Healthcare

$140K - $210K *

Advance clinical documentation quality through audits and education, guiding teams to improve coding integrity and regulatory compliance while promoting accurate documentation practices and enhancing...

3 days ago

  •   8 - 10 years exp.  •   Healthcare

$61K - $101K *

Lead the charge in medical coding oversight, training teams, and ensuring compliance. Utilize your expertise to communicate effectively with staff and clients while fostering quality and timely coding...

US-AnywhereRemote

Reposted today

  •   5 - 7 years exp.  •   Healthcare

$90K - $100K *

Elevate patient care by managing the medical-only Workers’ Compensation cases and conducting utilization reviews, ensuring quality treatment and timely return-to-work outcomes through collaboration wi...

4 weeks ago

  •   Less than 5 years exp.  •   Healthcare

$64K - $108K *

Pioneer initiatives for coding excellence by auditing records, developing educational programs, and driving compliance improvements. Collaborate with healthcare professionals to enhance documentation...

2 weeks ago

  •   5 - 7 years exp.  •   Healthcare

$64K - $108K *

Contribute to enhancing coding education by auditing records, developing training, and improving documentation strategies while ensuring compliance with coding guidelines and regulations...

US-AnywhereRemote

2 weeks ago

  •   5 - 7 years exp.  •   Healthcare

$80K - $95K *

Drive application support excellence by leading cross-functional collaboration, resolving issues, and enhancing user experience within clinical operations through Epic software expertise and effective...

Reposted 6 days ago

  •   Less than 5 years exp.  •   Hospitals & Medical Centers

$64K - $96K *

Engage in comprehensive risk adjustment audits and compliance reviews, ensuring accurate data submission to CMS. Collaborate with coding teams and management to uphold regulatory standards and improve...

US-AnywhereRemote

Yesterday

  •   Less than 5 years exp.  •   Healthcare

$93K - $132K *

Unlock potential by leveraging your nursing expertise in utilization management to ensure compliance with regulations and improve claim accuracy, serving as a crucial link between healthcare providers...

US-AnywhereRemote

2 weeks ago

  •   Less than 5 years exp.  •   Healthcare

$110K - $130K *

Drive continuous improvement in accreditation and compliance across health systems, overseeing risk management, surveys, and corrective actions, while partnering with leaders to ensure safe and reliab...

1 week ago

  •   5 - 7 years exp.  •   Healthcare

$86K - $129K *

Transform healthcare by auditing inpatient medical records to ensure accurate DRG billing. Leverage your clinical expertise to identify documentation errors and recommend process improvements essentia...

Reposted 5 days ago

  •   8 - 10 years exp.  •   Healthcare

$86K - $155K *

Lead the charge in clinical validation auditing by ensuring accurate documentation supporting inpatient claims, enhancing compliance, and promoting best practices within a flexible virtual environment...

1 week ago

  •   8 - 10 years exp.  •   Healthcare

Frequently Asked Questions (FAQ)

  • What is a Clinical Documentation Specialist?question toggle

    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?question toggle

    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?question toggle

    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?question toggle

    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.