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.
Director, Clinical Documentation Integrity - Remote
$112K - $193K *
Lead clinical documentation improvement efforts across multiple hospitals to enhance documentation quality, drive performance through analytics, and collaborate with healthcare leaders for optimal pat...
3 weeks ago
Director Inpatient Clinical Documentation Integrity | CentraCare
$117K - $175K *
Lead the advancement of clinical documentation initiatives by collaborating across departments to improve metrics, compliance, and financial outcomes while fostering a culture of excellence and contin...
Reposted 1 week ago
System Director, Clinical Documentation Integrity
$150K - $180K *
Elevate your career by leading clinical documentation initiatives across a diverse health system. Oversee strategies that ensure accurate patient complexity representation, enhance quality outcomes, a...
6 days ago
$100K - $125K *
Lead the coding team's efforts in driving operational excellence and revenue integrity. Oversee daily workflows and collaborate with clinical staff to enhance chart accuracy and coding processes in a...
3 days ago
Clin Documentation Spec III - Remote
$85K - $145K *
Engineer high-quality medical documentation processes through collaboration with healthcare teams, ensuring accuracy for optimal reimbursement and clinical outcomes while maintaining compliance with c...
3 weeks ago
Senior Clinical Documentation Specialist Float Pool
$87K - $121K *
Advance clinical documentation integrity by providing expert support across multiple markets, managing complex cases, and mentoring teams while ensuring adherence to high standards and seamless operat...
5 days ago
Auditor Clinical Validation Outpatient Specialty Clinical
$95K *
Unlock potential by auditing outpatient and specialty claims, ensuring coding accuracy, clinical necessity, and compliance with industry standards. Leverage advanced coding expertise to identify billi...
3 weeks ago
Supervisor, Payment Integrity- Coding & Clinical (DRG)
$87K - $157K *
Lead the Coding & Clinical Review team to ensure accurate DRG assignments, compliance, and operational excellence in Payment Integrity. Drive performance and quality while overseeing audits and collab...
1 week ago
Supervisor, Payment Integrity- Coding & Clinical (DRG)
$87K - $157K *
Supervise the Coding & Clinical Review team to ensure accurate DRG coding, compliance with standards, and operational efficiency, while implementing strategies that enhance team performance and uphold...
1 week ago
Documentation & Coding Consultant
$70K - $95K *
Champion the design and management of compliance and reimbursement practices, ensuring adherence to coding standards and regulatory requirements while fostering a culture of education and support with...
Reposted 2 weeks ago
Documentation & Coding Consultant
$70K - $95K *
Lead efforts to enhance documentation accuracy and coding compliance, ensuring optimal reimbursement and adherence to regulations. Collaborate with clinical departments to implement effective educatio...
Reposted 2 weeks ago
EpicCare Clinical Documentation Analyst
$85K - $137K *
Lead the charge in enhancing clinical documentation within EpicCare, driving optimization through workflow analysis, training, and support. Collaborate cross-functionally to tailor solutions that meet...
Yesterday
Director, Clinical Documentation Integrity - Arizona
$112K - $193K *
Elevate your career by leading a multi-hospital Clinical Documentation Integrity program. You'll oversee operations, drive performance, and collaborate with healthcare leaders to enhance clinical docu...
4 days ago
DRG Validation Auditor (Clinical & Coding)
$95K *
Lead the charge in clinical audit excellence by integrating coding principles and guidelines. You'll analyze inpatient claims and ensure compliance with standards, driving quality and accuracy in heal...
2 weeks ago
Supervisor, Clinical Documentation Coding & Auditing Services Compliance
$101K - $131K *
Join a team that's leading compliance activities and collaborating with stakeholders to optimize regulatory practices. Drive initiatives through analysis, reporting, and audits while mentoring a talen...
3 weeks ago
Senior Manager, Clinical Documentation Integrity
$147K - $190K *
Elevate clinical documentation quality by leading assurance reviews, compliance audits, and training programs. Drive process improvements and collaborate with medical teams to ensure accurate coding a...
5 days ago
Senior Director Coding Services
$147K - $183K *
Accelerate your career by leading strategic operations in Risk Adjustment Coding. Drive quality and efficiency while ensuring client satisfaction and operational excellence through collaboration and i...
5 days ago
$80K - $90K *
Engage in comprehensive claim investigations and adjustments, authorizing settlements and managing vendor relationships. This role offers growth potential in a team-oriented environment, delivering ex...
Reposted 2 weeks ago
Epic Certified EHR Systems Analyst I (ClinDoc)
$80K - $95K *
Empower progress at healthcare IT by leveraging Epic systems expertise to enhance application design and implementation. Collaborate with teams to address workflows, optimize efficiency, and support c...
Reposted 1 week ago
$78K - $82K *
The Prof Coding Specialist I is responsible for professional outpatient coding services, requiring interaction with physician office staff and billing personnel. Candidates should have knowledge of me...
Reposted 3 weeks ago
Manager, Clinical Quality Operations
$90K - $100K *
Drive excellence in clinical quality operations by managing a diverse network of practitioners, ensuring adherence to policies and performance targets, while providing strategic oversight and coaching...
3 days ago
**Manager- Outpatient Clinical Documentation Improvement/Full Time/Remote
$90K - $110K *
Manage clinical operations by providing expert leadership and guidance. Drive efficiency through strategic project management, fostering collaboration among physicians and staff while ensuring complia...
3 days ago
**Manager- Outpatient Clinical Documentation Improvement/Full Time/Remote
$85K - $100K *
Drive your career forward by leveraging clinical operations expertise to enhance revenue coding and reimbursement strategies, while leading transformative projects and fostering collaborative relation...
3 days ago
Team Lead, Clinical Documentation Improvement
$75K - $95K *
Unlock potential by leading clinical documentation improvement initiatives, overseeing performance, training, and audits. Ensure team productivity and compliance while educating staff and enhancing do...
2 weeks ago
Manager - Inpatient Clinical Coding
$75K - $95K *
Lead the Clinical Data Section, overseeing coding, abstracting, and data analysis of medical records to ensure compliance, improve revenue cycle management, and support hospital operations for enhance...
4 weeks 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.