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Clinical Documentation Review Jobs (NOW HIRING)

System Support

CLINICAL DOCUMENTATION SPEC

Walnut Hills, OH · On-site

$33.25 - $44.75/hr

CLINICAL DOCUMENTATION EXCELLENCEFull-Time / Day ShiftDescriptionIf you are motivated by the ... Complete admission reviews with the most appropriate principal diagnosis, complicating conditions ...

Premier Health

CLINICAL DOCUMENTATION SPEC

Dayton, OH · On-site

$33.75 - $45.50/hr

Complete admission reviews with the most appropriate principal diagnosis, complicating conditions ... Identify opportunities for documentation clarification and complete clinically based queries.

Premier Health

CLINICAL DOCUMENTATION SPEC

Dayton, OH · On-site

$33.75 - $45.50/hr

Complete admission reviews with the most appropriate principal diagnosis, complicating conditions ... Identify opportunities for documentation clarification and complete clinically based queries.

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Clinical Documentation Review information

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$18

$39

$59

How much do clinical documentation review jobs pay per hour?

As of Sep 11, 2026, the average hourly pay for clinical documentation review 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 review?

Clinical documentation review is the process of evaluating medical records to ensure that they accurately and thoroughly reflect the care provided to a patient. This review is often conducted by clinical documentation specialists or healthcare professionals to support proper coding, billing, and compliance with regulatory standards. Effective documentation review helps improve patient care, ensures accurate reimbursement, and minimizes legal risks for healthcare organizations.

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

To thrive as a Clinical Documentation Reviewer, you need a solid understanding of medical terminology, coding standards (such as ICD-10, CPT), and healthcare regulations, typically supported by a background in nursing, health information management, or a related field. Familiarity with electronic health record (EHR) systems, clinical documentation improvement (CDI) software, and relevant certifications like CCDS or CDIP is often required. Attention to detail, analytical thinking, and strong communication skills help ensure accurate documentation and effective collaboration with healthcare providers. These skills and qualifications are vital for maintaining compliance, optimizing reimbursement, and ensuring high-quality patient care documentation.

What are some common challenges faced in a clinical documentation review role, and how can they be addressed?

Professionals in Clinical Documentation Review often encounter challenges such as incomplete or ambiguous patient records, tight deadlines for documentation audits, and the need to stay updated with evolving regulatory requirements. Addressing these challenges involves strong attention to detail, effective collaboration with healthcare providers to clarify discrepancies, and ongoing education on compliance standards. Many teams utilize regular meetings and training sessions to ensure best practices are shared and documentation remains accurate and thorough.

What is the difference between Clinical Documentation Review vs Medical Records Reviewer?

AspectClinical Documentation ReviewMedical Records Reviewer
CertificationsAHIMA or AAPC credentials often preferredSimilar certifications may be required, but less specialized
Work EnvironmentHealthcare facilities, insurance companies, or coding companiesHospitals, clinics, insurance companies
Job FocusAssessing and improving clinical documentation accuracyReviewing medical records for completeness and compliance
Common UsageUsed in clinical quality, coding, and reimbursement processesUsed mainly for record accuracy and legal purposes

Both roles involve reviewing medical information, but Clinical Documentation Review focuses on evaluating and enhancing clinical documentation quality, while Medical Records Reviewer concentrates on verifying record completeness and compliance. Understanding these differences helps professionals choose the right career path or job search focus.

How to become a clinical documentation review?

To become a clinical documentation reviewer, candidates typically need a healthcare-related degree such as nursing, health information management, or a related field. Relevant experience in clinical settings, knowledge of medical coding and documentation standards, and familiarity with electronic health record systems are also important. Certification in medical coding or health information management can enhance job prospects.
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What states have the most Clinical Documentation Review jobs?

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

What are popular job titles related to Clinical Documentation Review jobs?

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Clinical Documentation Review jobs near you
Infographic showing various Clinical Documentation Review 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 Spec

Loma Linda, CA • On-site

Loma Linda University Health
Health Care and Social Assistance • 10K+ employees
Learn more about Loma Linda University Healthexternal

$35.75 - $48/hr

Full-time

This job post has expired 3 days ago. Applications are no longer accepted.

Loma Linda University Health rating

8.2

Company rating: 8.2 out of 10

Based on 88 frontline employees who took The Breakroom Quiz

Job description

MC: Clinical Documentation Imp- (Full Time, Days) - 

Job Summary: The Clinical Documentation Specialist is responsible for concurrent clinical documentation review with an emphasis on completeness and accuracy of provider documentation related to intensity of service required and severity of illness upon hospitalization and throughout patient stay. Initiates communication, verbal and written, with providers to facilitate clarification of need for greater specialty or completeness of the medical record. Provides formal education related to documentation integrity and completeness at medical staff department meetings and committees. Keeps physician leaders in areas of responsibility informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity. Performs other duties as needed.
Education and Experience: Bachelor's Degree in Nursing from an accredited school or Bachelor's Degree in Health Information Management (HIM) required. Bachelor's Degree in Nursing in progress acceptable with quarterly updates provided. Minimum three years of acute hospital nursing or acute hospital coding experience required. For nurses filling role one year of recent (within one year) acute care nursing experience required. Critical Care or ED experience preferred. For CDS members practicing in pediatric areas, minimum three years of pediatric acute hospital nursing experience required, PICU or NICU preferred.
Knowledge and Skills: Recent experience as acute hospital utilization reviewer or Case Manager with knowledge of third party reimbursement requirements preferred.  Able to read; write legibly; speak in English with professional quality; use computer and software programs necessary to the position; troubleshoot and calibrate patient care equipment.  Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction.  Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; performs basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail.  Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place or patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch. 
Licensures and Certifications: California Registered Nurse (RN) License required for nurse filling role.

Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.
Loma Linda University Health is a Seventh-day Adventist, faith and values based Christian institution. Candidates must understand and embrace the mission, purpose, and identity of Loma Linda and its affiliated entities.

We are an equal opportunity employer committed to the principles of diversity. We provide equal opportunities in all aspects of the employment process to every individual, regardless of gender, race, color, age, national origin, ancestry, physical or mental disability, marital or veteran status, genetic information or any other characteristic protected by law. In addition, we will provide reasonable accommodations for otherwise qualified individuals requesting an accommodation due to a disability. If you need accommodation assistance with accessing our job listings or completing an application, or during any other phase of employment with us, please contact Human Resources Management at (909) 651-4001.

Loma Linda University Medical Center is a religiously-qualified Equal Opportunity Employer under Title VII of Civil Rights Act of 1964. No question on this application is asked for the purpose of unlawfully limiting or excluding any applicant's consideration for employment because of race, color, religion, gender, age, national origin, disability, genetic information, or any other status protected by applicable law. If you need a reasonable accommodation in the hiring process, please notify Human Resource Management.

We appreciate your interest in Loma Linda and wish you success in your job search!

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About Loma Linda University Health

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Loma Linda University Health (LLUH) is an esteemed healthcare organization situated in Loma Linda, California, US. Established in 1905, it was initially known as the College of Medical Evangelists, and it operated as the official medical institution of the Seventh-day Adventist Church until the name was changed to LLUH in 1961. LLUH is very much active in the healthcare and education sectors, providing a vast range of services such as medical treatment, research, and health education. The organization’s core mission is "to continue the teaching and healing ministry of Jesus Christ", which underlines its binding values of compassion, integrity, excellence, freedom, and justice.

Industry

Health care and social assistance and hospitality services

Company size

10,000+ Employees

Headquarters location

Loma Linda, CA, US

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