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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1
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$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...

US-AnywhereRemote

2 weeks ago

  •   5 - 7 years exp.  •   Healthcare

$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

  •   Less than 5 years exp.  •   Healthcare

$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

  •   Less than 5 years exp.  •   Healthcare

$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...

US-AnywhereRemote

1 week ago

  •   11 - 15 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

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

$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

  •   Less than 5 years exp.  •   Healthcare

$80K - $80K *

Transform how we nourish our residents by leading a dedicated Dietary Department. Drive meal planning, quality control, and team management to ensure exceptional nutrition and compliance. Your leaders...

1 week ago

  •   Less than 5 years exp.  •   Healthcare

$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...

US-AnywhereRemote

Reposted 1 week ago

  •   Less than 5 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Hospitals & Medical Centers

$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

  •   8 - 10 years exp.  •   Hospitals & Medical Centers

$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...

US-AnywhereRemote

4 days ago

  •   5 - 7 years exp.  •   Healthcare

$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

  •   5 - 7 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Healthcare

$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

  •   Less than 5 years exp.  •   Healthcare

$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

  •   8 - 10 years exp.  •   Hospitals & Medical Centers

$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

  •   8 - 10 years exp.  •   Hospitals & Medical Centers

$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

  •   8 - 10 years exp.  •   Hospitals & Medical Centers

$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

  •   8 - 10 years exp.  •   Hospitals & Medical Centers

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.