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.
Epic Certified EHR Systems Analyst II (ClinDoc)
$90K - $120K *
Optimize healthcare IT systems as an Epic-Certified EHR Systems Analyst III. Collaborate with teams on design, build, implementation, and support functions while ensuring efficient workflows and user...
2 weeks ago
Medical Policy Release Manager
$105K - $125K *
Lead the charge in managing medical policy releases, ensuring compliance, quality assurance, and stakeholder communication to optimize deployment in a dynamic healthcare environment...
4 days ago
Inpatient Coding Data Quality Auditor/Educator
$98K - $142K *
Engage in vital quality audits and education to enhance inpatient coding accuracy, supporting optimal DRG reimbursement and data integrity. Collaborate with a dedicated team to elevate clinical docume...
Reposted 2 weeks ago
Compliance Audit / Investigator - CCS / CPC / or CCA
$65K - $117K *
Shape compliance strategies by conducting provider audits, enhancing billing integrity, and engaging with government inquiries. Utilize analytical skills to drive improvements in our auditing processe...
Reposted 3 weeks ago
Inpatient Coder Associate, Payment Integrity
$80K - $110K *
Empower accuracy in medical claims by collaborating on DRG validation. You will review claims, identify overpayments, and build relationships across teams to enhance compliance and operational efficie...
3 weeks ago
$94K - $111K *
Lead the charge in optimizing coding practices to enhance revenue, ensure compliance, and drive performance improvements. Collaborate with cross-functional teams to implement strategic initiatives tha...
1 week ago
Manager of DRG Coding & Clinical Validation Audit
$115K - $207K *
Lead a team in ensuring accurate DRG coding and compliance audits. Collaborate across departments to enhance audit strategies, oversee team growth, and maintain high industry standards while driving p...
3 weeks ago
Manager of DRG Coding & Clinical Validation Audit
$115K - $207K *
Oversee and enhance DRG coding audits, drive compliance initiatives, and lead a talented team to ensure accurate medical record audits. Collaborate across departments to optimize strategies and maximi...
3 weeks ago
Manager of DRG Coding & Clinical Validation Audit
$115K - $207K *
Shape the future of healthcare auditing by leading a dynamic team in DRG coding and clinical validation. Drive strategic initiatives, ensure compliance, and enhance operational efficiency to improve p...
3 weeks ago
Manager of DRG Coding & Clinical Validation Audit
$115K - $207K *
Drive impactful auditing by leading a high-performing team in DRG coding. Shape strategic audit methodologies, ensure compliance, and collaborate across functions to optimize clinical validation and e...
3 weeks ago
Manager of DRG Coding & Clinical Validation Audit
$115K - $207K *
Transform the landscape of healthcare auditing by leading a dynamic team in ensuring DRG coding accuracy and compliance. Drive strategic initiatives, enhance audit methodologies, and collaborate acros...
3 weeks ago
Manager, Compliance - Clinical Documentation Coding & Auditing Services
$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...
2 days ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Join a dynamic team as a clinical validation auditor to analyze inpatient medical records and ensure accurate DRG coding. Leverage your nursing expertise to enhance quality standards and drive process...
1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Unlock advanced clinical coding insights by leading audits of inpatient medical records. Collaborate with healthcare professionals to ensure accurate DRG assignments and drive improvements in clinical...
1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Manage the auditing of inpatient medical records for accuracy, ensuring compliance with DRG-related billing. Leverage your expertise in ICD-10 coding and clinical guidelines to enhance documentation i...
1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Analyze, audit, and validate DRG claims to ensure accurate clinical documentation. Collaborate with healthcare teams and utilize coding expertise to enhance audit processes and improve efficiency with...
1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Empower our clinical documentation integrity by auditing inpatient medical records. Utilize your expertise in DRGs and coding to ensure compliance, enhance quality, and promote efficiency in patient c...
1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Engage in detailed audits of inpatient medical records, ensuring clinical documentation aligns with billed diagnoses. Utilize coding expertise to enhance accuracy in claims and provide actionable insi...
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 enhancing clinical accuracy by auditing inpatient records. Leverage your RN license and coding expertise to support effective documentation and ensure compliance with D...
1 week ago
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
$86K - $155K *
Shape patient outcomes by auditing inpatient medical records to ensure clinical documentation aligns with billed DRGs. Utilize advanced coding knowledge and audit tools to identify errors and recommen...
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 ensuring accurate clinical documentation and reimbursement. Leverage your auditing expertise and coding knowledge to analyze inpatient medical records and enhance healt...
1 week ago
DME Documentation Criteria Reviewer
$75K - $95K *
Provide critical analysis of patient documentation to ensure compliance with medical necessity criteria and payer policies, enhancing the accuracy and efficiency of documentation processes...
3 weeks ago
Associate Director of Revenue Cycle (Billing and Coding)
$90K - $120K *
Champion revenue cycle efficiency by overseeing coding and billing processes, driving strategic initiatives, and enhancing patient collection workflows to optimize operations and boost revenue while e...
2 weeks ago
Clinical Provider Auditor II - Payment Integrity SIU
$58K - $107K *
Explore opportunities to enhance fraud prevention through detailed claim audits, collaborating cross-functionally to mitigate risks and recommending interventions while maintaining up-to-date knowledg...
3 weeks ago
Clinical Provider Auditor II - Payment Integrity SIU
$58K - $107K *
Lead critical audits in healthcare payment integrity by assessing claims, preventing fraud, and collaborating with teams to enhance compliance. Drive risk management initiatives and contribute to bett...
3 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.