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.
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Empower healthcare accuracy by conducting thorough audits of medical records to validate clinical documentation for DRGs, ensuring compliance and reimbursement integrity while leveraging coding expert...
Reposted 1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Engage in clinical validation auditing by analyzing medical records to ensure accuracy in diagnosis-related group coding, supporting billing and reimbursement processes while enhancing documentation q...
Reposted 1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Join a team that's dedicated to auditing clinical documentation to ensure accuracy and compliance. This role requires advanced expertise in diagnosis coding and a commitment to maintaining exceptional...
Reposted 1 week ago
$75K - $95K *
Empower the coding team by leading audits, education, and process improvements. Enhance documentation and coding accuracy while ensuring timely billing and compliance within the healthcare setting...
3 days ago
Clinical Data Standard Consultant
$90K - $130K *
Join a team that's at the forefront of defining clinical data standards. Lead initiatives to enhance data analysis efficiency, mentor professionals, and collaborate with industry leaders to drive inno...
2 days ago
Senior Compliance Coding Auditor
$75K - $95K *
Transform compliance through expert coding audits, reporting, and education, ensuring adherence to guidelines. Collaborate with leadership to mitigate risks and foster continuous improvement across va...
Today
$88K - $142K *
Join a team that's dedicated to coordinating complex care for vulnerable populations, focusing on empowering members while ensuring efficient use of resources and collaboration among healthcare profes...
4 weeks ago
Region Manager Revenue Cycle Coding-CDI Audit - Educ-CentNWSo
$90K - $120K *
Transform the coding and CDI landscape by leading audit and education initiatives, ensuring compliance and enhancing performance across teams. Drive training development and process improvement to fos...
1 week ago
$120K - $150K *
Serve as a strategic leader overseeing coding and documentation integrity, ensuring compliance and optimizing processes across inpatient and outpatient settings. Collaborate with cross-functional team...
3 weeks ago
Manager, Clinical Quality Operations
$90K - $100K *
Champion excellence in clinical operations by managing field practitioners, ensuring compliance and quality care, and driving operational success in a dynamic healthcare environment. Lead innovative t...
6 days ago
Coding Auditor & Educator Lead
$70K - $95K *
Lead the coding audit and education operations, managing personnel, facilitating training, and ensuring standardization across the region, driving quality and productivity in healthcare coding service...
Reposted 3 days ago
Coding Auditor & Educator Lead
$75K - $95K *
Elevate coding audit and education operations, guiding teams and enhancing quality reviews. Collaborate in training hospital coders while ensuring compliance and standardization across the region to s...
Reposted 1 week ago
Clinical Quality Assurance Specialist - Trauma Program
$74K - $107K *
Elevate patient care by leading trauma process improvements and safety initiatives. Collaborate with multidisciplinary teams to analyze data, implement best practices, and enhance clinical outcomes in...
3 weeks ago
Clinical Informaticist / Clinical Coder
$73K - $132K *
Advance military health research by performing clinical coding and data management. Collaborate with diverse professionals to ensure accuracy and integrity of health records, aiding in the improvement...
2 weeks ago
Content Specialist, Healthcare Consumer Experience
$70K - $95K *
Pioneer impactful patient engagement by transforming behavioral science into compelling content. Collaborate with cross-functional teams to drive healthcare improvements while utilizing innovative AI...
Reposted today
$114K - $141K *
Empower elderly patients by delivering personalized nursing care in various settings. Collaborate with interdisciplinary teams and support chronic condition management while ensuring high-quality pati...
4 weeks ago
Director of Nursing Specialist (RN)
$90K - $97K *
Lead the charge in fostering a high-quality health and wellness environment, managing teams, ensuring compliance with regulations, and mentoring new directors. Champion resident care through strategic...
3 weeks ago
Region Manager Revenue Cycle Coding-CDI Audit - Educ-CentNWSo
$90K - $120K *
Pioneer the development of coding and CDI educational strategies, managing a dedicated team to enhance compliance, drive improvement initiatives, and foster professional growth in alignment with regul...
1 week ago
Epic Analyst 2 - Care Inpatient & Clinical Documentation, Full Time, Days
$75K - $95K *
Take ownership of the build, configuration, and support of Epic modules, ensuring efficient workflows and compliance. Collaborate with stakeholders to translate complex requirements into effective tec...
3 weeks ago
Manager of Credentialing - Revenue Cycle Management (RCM)
$75K - $95K *
Lead provider credentialing and payer enrollment for a dynamic ambulance organization. Oversee compliance operations and enhance revenue cycle performance while managing a team dedicated to operationa...
2 weeks ago
Medical Records Coder Supervisor (Inpatient)
$75K - $95K *
Transform healthcare documentation accuracy by leading a skilled coding team. This role emphasizes compliance, operational excellence, and continuous improvement in medical coding processes while fost...
2 weeks ago
$83K - $93K *
Shape the future of healthcare through enhanced clinical documentation quality, ensuring thorough medical records and accurate coding. Collaborate with providers to elevate patient care and compliance...
6 days ago
Region Manager Revenue Cycle CDI-Central
$90K - $120K *
Lead the charge in optimizing CDI team performance and compliance. Play a vital role in achieving strategic goals, driving collaboration across departments, and enhancing the accuracy of inpatient med...
Reposted 2 days ago
$72K - $130K *
Transform clinical workflows by supporting and optimizing Epic ClinDoc functionality. Collaborate with clinical teams and IT partners to ensure seamless integration and compliance while enhancing user...
5 days ago
Documentation Integrity Specialist IV, Clinical Licensure
$133K - $172K *
Shape the future of clinical documentation improvement by reviewing medical records and ensuring accuracy. Collaborate with teams to enhance compliance and conduct staff training to drive excellence i...
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.