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Clinical Documentation Jobs (NOW HIRING)

Northwell

Clinical Documentation Specialist

Lake Success, NY · On-site

$37 - $49.75/hr

Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care ...

Northwell

Clinical Documentation Specialist

Lake Success, NY · On-site

$37 - $49.75/hr

Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care ...

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Clinical Documentation information

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$18

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$59

How much do clinical documentation jobs pay per hour?

As of Aug 20, 2026, the average hourly pay for clinical documentation in the United States is $39.30, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $44.95 per hour, depending on experience, location, and employer.

What is clinical documentation?

Clinical documentation refers to the process of recording detailed information about a patient's medical history, diagnoses, treatments, and care in a healthcare setting. This documentation is critical for ensuring accurate communication among healthcare providers, supporting quality patient care, and fulfilling legal and billing requirements. Proper clinical documentation also helps in coding for insurance claims and maintaining compliance with healthcare regulations. It typically involves both handwritten and electronic records, and professionals involved may include physicians, nurses, and clinical documentation specialists.

What are the key skills and qualifications needed to thrive as a clinical documentation specialist?

To thrive as a Clinical Documentation Specialist, you need a strong understanding of medical terminology, anatomy, disease processes, and clinical coding, typically supported by a background in healthcare and certifications such as CCDS or CDIP. Familiarity with electronic health record (EHR) systems, coding software, and clinical documentation improvement (CDI) tools is crucial. Attention to detail, analytical thinking, and effective communication with healthcare providers are standout soft skills in this role. These competencies ensure accurate and comprehensive clinical records, which are vital for patient care quality, regulatory compliance, and optimal reimbursement.

What are some common challenges faced by professionals in clinical documentation, and how can they be addressed?

One common challenge in Clinical Documentation is ensuring accuracy and completeness while working under tight deadlines. Documentation specialists must interpret complex medical information and maintain compliance with regulatory standards, which can be demanding. Collaborating closely with physicians and other healthcare staff helps clarify ambiguities, and ongoing training keeps professionals updated on coding changes and best practices. Embracing technology, such as electronic health records (EHRs), also streamlines workflows and reduces errors.

What is the difference between Clinical Documentation vs Medical Records Technician?

AspectClinical DocumentationMedical Records Technician
CertificationsNone required, but certifications like CCDS can be beneficialRegistered Health Information Technician (RHIT) or Certified Medical Records Technician (CMRT)
Work EnvironmentHospitals, clinics, healthcare facilities, often involved in clinical settingsMedical records departments, healthcare facilities, focusing on record management
Primary ResponsibilitiesCreating, managing, and ensuring accuracy of clinical documentation for patient careOrganizing, coding, and maintaining patient health records and data

While both roles involve handling healthcare information, Clinical Documentation focuses on creating and managing detailed clinical records to support patient care and billing, whereas Medical Records Technicians primarily organize and maintain patient records for administrative purposes. Understanding these differences helps healthcare organizations assign the right roles for accurate documentation and record management.

More about Clinical Documentation jobs

What cities are hiring for Clinical Documentation jobs?

Cities with the most Clinical Documentation job openings:

What are the most commonly searched types of Clinical Documentation jobs?

The most popular types of Clinical Documentation jobs are:

What states have the most Clinical Documentation jobs?

States with the most job openings for Clinical Documentation jobs include:

Clinical Documentation jobs near you
Infographic showing various Clinical Documentation job openings in the United States as of August 2026, with employment types broken down into 2% As Needed, 71% Full Time, 22% Part Time, 4% Contract, and 1% Nights. Highlights an 93% Physical, 2% Hybrid, and 5% Remote job distribution, with an average salary of $81,742 per year, or $39.3 per hour.

Clinical Documentation Specialist - Clinical Documentation

Shannon Medical

San Angelo, TX • On-site

$33.50 - $45/hr

Full-time

Re-posted 28 days ago

Job description

Job Summary

The clinical documentation specialist works collaboratively with providers and coding staff to ensure that the documentation in the medical record accurately reflects the quality and level of care provided. The overall goal of the position is to improve clinical documentation for quality assurance and revenue compliance and integrity. 

Scope & Impact: Through clinical validation queries emphasizing a reduction in reported hospital-acquired conditions and increasing clinical evidence in support of certain ICD-10 guidelines, the CDI specialist is responsible for several initiatives including but not limited to: reimbursement methodologies, data stewardship and collection, quality measures, medical necessity, and denial prevention.

Physical Requirements

  • The ability to perform the duties and responsibility of the position, with or without reasonable accommodations for disabilities. 
  • The ability to consistently lift, push or pull loads of up to fifty (50) pounds. (Unless nursing 50)
  • Sufficient strength, mobility and stamina to make frequent location and position changes, assist with patient care, and perform other physical activities of average difficulty.  
  • Candidates whose disabilities make them unable to meet the requirements will still be considered fully qualified if they can perform the essential functions of the job with reasonable accommodations.
  • May be exposed to infectious or contagious disease.
  • May have to handle emergency situations.
  • May be subject to irregular hours.
  • May be required to wear protective equipment such as eye protection, face protection, masks, sterile/nonsterile gloves, isolation gowns.
  • May be exposed to toxic/caustic/chemicals/detergents.            
  • Physical activities include continuous sitting, and occasional walking, standing, bending, squatting, climbing, kneeling and twisting.
  • Activity Conditions (Occasionally, Frequently, Continuously):
    • Sitting- Continuously 
    • Walking- Frequently  
    • Standing- Frequently  
    • Bending-Frequently  
    • Squatting- Occasionally 
    • Climbing-Occasionally
    • Kneeling-Occasionally
    • Twisting-Occasionally

Visual and Hearing Requirements

  • Must be able to see with corrective eye wear.

  • Must be able to hear clearly with assistance. 

Working Conditions

Primarily Works in a well-lighted and air-conditioned environment with period of heavy workload and stress. This role may include working in less-than-ideal home conditions, which can include exposure to extreme temperatures and environments that may not meet typical cleanliness standards such as clutter, unkept surfaces, and homes with pets. Works in various conditions. 

Performance: Essential Functions

Decision Making: Ability to make decisions and takes appropriate action based on the information they have. Recognizes own limitations and consults with the supervisor, manager, or team member when appropriate.

Time Management: Works efficiently and manages duties to ensure that tasks are completed with accuracy and within the scheduled shift or reasonable amount of time.

Quality & Quantity: Demonstrates accurate, knowledge and skill to carry out job duties. Follows departmental work policies and procedures. Speed and consistency of output, and time utilization of job duties.

Computer Knowledge & Electronic Equipment Use: Demonstrates ability to consistently utilize electronic equipment and online computer programs to perform job duties, including electronic documentation, and order entry.

Resource Utilization: Consistently utilizes and maintains supplies and equipment to minimize lost charges and unnecessary equipment repair-replacement.

Confidentiality: Adheres to established policies on privacy and security requirements for compliance with the Health Insurance Portability and Accountability Act (HIPAA), as applicable by Shannon Policy.

Qualifications

Education

  • Required 

    • High School Diploma, GED, or equivalent 

    • Associate's degree in Nursing 

  • Preferred

    • Bachelor's degree in Nursing or clinical related field 

    • Doctor of Medicine 

      • Required in lieu of a licensed Registered Nurse 

Experience:

  • Preferred

    • One year of experience in Clinical Documentation improvement and/or clinical coding

    • Three years of experience in acute care, hospital setting, or case management 

Certification/Licensure:

  • Required

    • Registered Nurse (RN), with authorization to practice in the State of Texas 

      • Unless a Medical Doctor 

  • Preferred

    • RHIT/RHIA/CDIP/CCDS or clinical documentation certification 

Supervises the Following Positions

Positions: N/A

Performance: Position Specific Essential Functions

  • Collecting patient information related to diagnosis and course of care by conducting daily chart reviews.

  • Assessing documentation validity utilizing CDI analytic software and critical thinking skills

  • Identifying and communicating query opportunities with providers (for needed documentation support, ambiguity, or conflict).

  • Meeting productivity requirements by maintaining daily/weekly query rate.

  • Communicating with coding, providers, and applicable team members on documentation improvement needs.

  • Upholding the integrity of the hospital medical record by complying with organizational, legal, ethical, and regulatory requirements. 

  • Providing superior customer service to customers and coworkers with professional conduct and respectful behavior. 

  • Strong interpersonal skills that allow for effective communication with different levels of hospital personnel

  • Solid verbal and written communication skills required. 

  • Organization, prioritization, critical thinking, and attention to detail are needed. 

  • Basic computer and office equipment knowledge; Electronic Medical Record training provided.

  • Prior knowledge of medical and pharmacology terminology required.

  • Performs other duties as assigned.

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