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Clinical Documentation Nurse Jobs (NOW HIRING)

Comtech, LLC

Clinical Documentation Specialist

Bethesda, MD

$37.25 - $50/hr

The Clinical Documentation component is used by physicians, nurses and ancillary department staff to document procedures, patient status, and other clinical components. We are seeking 2resources to ...

Honorhealth

RN Clinical Documentation

Phoenix, AZ · Remote

$32.75 - $44/hr

Skilled Nursing Shift: Day Department: Clinical Documentation Option to work fully remote or in-office near Deer Valley, AZ. Must reside in the state of Arizona. Training for the first eight (8) ...

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Clinical Documentation Nurse information

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$39.5K

$108.4K

$163K

How much do clinical documentation nurse jobs pay per year?

As of Aug 21, 2026, the average yearly pay for clinical documentation nurse in the United States is $108,414.00, according to ZipRecruiter salary data. Most workers in this role earn between $82,500.00 and $146,500.00 per year, depending on experience, location, and employer.

What is a clinical documentation nurse?

A Clinical Documentation Nurse (CDN) is responsible for reviewing patient medical records to ensure accurate and complete documentation of diagnoses, treatments, and procedures. They collaborate with healthcare providers to clarify medical records, ensuring compliance with coding regulations and reimbursement policies. By improving documentation quality, CDNs help optimize hospital revenue, enhance patient care, and support accurate reporting of healthcare data. This role requires strong clinical knowledge, attention to detail, and effective communication skills.

What are the typical daily responsibilities of a clinical documentation nurse?

Clinical Documentation Nurses spend their days reviewing patient medical records, assisting physicians and care teams in accurate charting, and identifying opportunities to clarify or improve clinical documentation. They often collaborate with doctors, case managers, and coding specialists to ensure correct and complete patient information for billing and regulatory purposes. In addition, they may conduct educational sessions with clinical staff to promote best documentation practices. This position is vital for ensuring medical records reflect the true complexity and acuity of patient care, which supports both high-quality care delivery and organizational compliance.

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

A Clinical Documentation Nurse requires a comprehensive understanding of clinical processes, healthcare terminology, and nursing best practices, typically supported by an active RN license and experience in patient care. Familiarity with electronic health record (EHR) systems, clinical documentation improvement (CDI) software, and relevant certifications—such as CCDS (Certified Clinical Documentation Specialist)—are highly valuable. Strong attention to detail, analytical thinking, and effective communication skills help these professionals collaborate with healthcare teams and ensure completeness and accuracy in records. These skills are essential for optimizing patient outcomes, facilitating accurate coding and billing, and maintaining regulatory compliance in healthcare organizations.

Are clinical documentation nurses in demand?

Clinical documentation nurses are in demand due to the need for accurate medical records and compliance with healthcare regulations. They often work in hospitals, clinics, and health information management settings, requiring strong clinical knowledge and attention to detail. The role is expected to grow as healthcare organizations prioritize documentation quality and coding accuracy.
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Clinical Documentation Nurse jobs near you
Infographic showing various Clinical Documentation Nurse 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 $108,414 per year, or $52.1 per hour.

Clinical Documentation Auditor

Centers Home

Pompano Beach, FL

Full-time

Re-posted 24 days ago

Job description

Job Description: Clinical Documentation Auditor ? CHHA

Department: Compliance / Clinical Review / Care Standards

Reports To: VP of Clinical Operations

Position Summary

The Clinical Documentation Auditor is responsible for reviewing clinical documentation across patient charts to ensure accuracy, completeness, and compliance with regulatory, payer, and agency standards. The auditor provides feedback to clinicians and leadership, helps identify documentation trends, and supports ongoing quality improvement initiatives within the Certified Home Health Agency (CHHA).

Key Responsibilities

  • Perform routine and focused audits of patient charts for:
    - Timely completion of Start of Care (SOC), Recertification, and Discharge OASIS
    - Visit documentation (nursing, therapy, aide)
    - Plan of Care compliance
    - MD order management and signed/verbal order tracking
    - Medication reconciliation
    - Visit frequency adherence
    - Missed visit documentation and follow-up
    - Care coordination and patient goals documentation
    - Assessment of comorbid conditions, safety, and environment
  • Verify that documentation supports medical necessity, homebound status, and meets payer requirements (including Medicare).
  • Identify gaps, trends, or inconsistencies in documentation and escalate as appropriate.
  • Collaborate with clinical leadership to provide feedback and education to field staff.
  • Assist in preparing for surveys and audits by regulatory or accrediting bodies.
  • Participate in development and updating of internal audit tools and workflows.
  • Maintain up-to-date knowledge of CHHA regulations, Medicare Conditions of Participation, and payer documentation requirements.

    Apply