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.
Auditor Clinical Validation OPSP Coding
$95K *
Unlock potential in outpatient and specialty audits by leveraging clinical and coding expertise. Conduct thorough claim audits, ensuring accuracy, compliance, and identifying improvement opportunities...
2 weeks ago
$70K - $95K *
Make your mark at a pivotal role driving cancer data management and analysis, ensuring compliance with accreditation standards. Collaborate effectively with multidisciplinary teams to support cancer p...
3 weeks ago
Epic Analyst -ASAP/ClinDoc/Orders/UC
$90K - $120K *
Join our team to enhance patient care by optimizing Epic applications. You’ll collaborate with clinicians, configure systems, and ensure users receive top-notch support and training in a dynamic healt...
Reposted 5 days ago
SVP, Quality, Risk Adjustment, & Documentation
$250K - $330K *
Drive excellence in quality, risk adjustment, and documentation, integrating critical functions to improve payer performance and financial sustainability in value-based care. Lead a transformative str...
1 week ago
AVP of Clinical Documentation Integrity
$120K - $150K *
Lead the charge in enhancing clinical documentation integrity through strategic oversight, collaboration with cross-functional teams, and the development of efficient processes to achieve organization...
1 week ago
Claims Clinical Specialist - Medical Review Team
$67K - $124K *
Unlock potential as you drive clinical excellence and support policyholders by enhancing case management processes and improving in-house certification functions through assessments and collaboration...
Today
System Director of Case Management - SDCM 0416 NS#15
$88K - $122K *
Champion high-quality patient care by leading case management functions, ensuring regulatory compliance, and driving performance improvement across the healthcare system while collaborating with inter...
Reposted 5 days ago
Certified Dietary Manager(CDM)
$80K - $80K *
Champion dietary excellence by leading meal planning and delivery, ensuring compliance and resident satisfaction. Drive a collaborative team culture in a fast-paced environment focused on nutrition an...
1 week ago
$70K - $126K *
Lead the charge in ensuring accurate MS-DRG and APR-DRG coding while exercising autonomy in clinical documentation reviews. Collaborate with medical experts to optimize compliance and enhance reimburs...
Reposted 1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Elevate operational efficiency by auditing inpatient records to ensure compliance with clinical documentation and reimbursement practices, utilizing advanced coding expertise, and fostering continuous...
Reposted 1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Lead the charge in auditing inpatient medical records to ensure clinical documentation aligns with billed DRGs, enhancing operational accuracy and efficiency in a supportive virtual environment...
Reposted 1 week ago
$75K - $95K *
Elevate healthcare outcomes by utilizing your expertise as a DRG Downgrade Appeals Clinician, performing clinical reviews and crafting compelling appeal documentation to support medical necessity and...
4 days ago
$100K - $130K *
Lead the charge in ensuring coding compliance and audit integrity in health plan operations, focusing on regulatory adherence and documentation accuracy while fostering collaboration across teams to e...
2 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$82K - $155K *
Optimize clinical documentation accuracy by auditing inpatient records, ensuring compliance with DRG guidelines. Leverage extensive coding expertise to enhance quality assurance in billing practices w...
2 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$82K - $155K *
Transform the quality of healthcare documentation by auditing inpatient medical records and ensuring compliance with DRG billing standards while driving efficiency in clinical validation processes...
2 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$82K - $155K *
Empower accurate clinical documentation by auditing inpatient records, ensuring compliance with billing regulations and DRGs. Utilize your expertise in ICD-10 coding and process improvement to enhance...
2 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$82K - $155K *
Transform your career with a vital role in clinical audit. Leverage your nursing expertise to ensure accuracy in DRG billing and compliance while driving quality improvements and enhancing patient car...
2 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$82K - $155K *
Analyze and audit clinical documentation for accuracy in billing by leveraging coding principles. Collaborate on quality improvement initiatives while ensuring adherence to established standards and p...
2 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$82K - $155K *
Unlock potential by auditing inpatient medical records for clinical compliance and accuracy. Leverage your extensive experience with DRGs and ICD coding to ensure proper billing, improve documentation...
2 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$82K - $155K *
Oversee and audit inpatient medical records to ensure accurate clinical documentation, supporting billing via DRGs. Utilize advanced coding expertise to identify errors and improve processes, ensuring...
2 weeks ago
$75K - $95K *
Join our team to optimize Epic EHR applications, bridging communication between users and leaders to enhance clinical documentation processes and workflows effectively within healthcare settings...
3 weeks ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Transform clinical documentation accuracy by auditing inpatient records to ensure DRGs align with billed conditions. Leverage extensive coding expertise and analytical skills to enhance quality and co...
Reposted 1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Optimize clinical documentation audits by leveraging extensive RN expertise in DRG validations, claims analysis, and coding accuracy to ensure compliance and improve healthcare outcomes within a flexi...
Reposted 1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Lead the audit of inpatient medical records to validate clinical documentation and uphold DRG billing accuracy. Leverage extensive coding expertise and analytical skills to enhance quality assurance a...
Reposted 1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Bring your expertise to the role of Clinical Validation Auditor, where you will analyze claims and ensure compliance with clinical documentation standards while enhancing operational efficiency and qu...
Reposted 1 week 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.