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Clinical Documentation Review Jobs (NOW HIRING)

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.

Centers Home

Clinical Documentation Specialist

Margate, FL

$31.50 - $42.50/hr

Clinical Documentation Specialist (RN/LPN) - Full Time Location: On-site - Staten Island, NY ... This is a full-time, on-site role responsible for auditing and reviewing patient charts to ensure ...

Midland Health

Clinical Documentation Specialist

Midland, TX · On-site

$34 - $46/hr

ESSENTIAL FUNCTIONS • Provides concurrent review of the clinical documentation in the medical records. • Concurrently queries the medical staff and other caregivers as necessary via written ...

COMPASSUS

Clinical Documentation Specialist

Seattle, WA · Remote

$39.50 - $53.25/hr

The Clinical Documentation Specialist works closely with the Manager of Quality Improvement and ... Responsible for the timely review and processing of Start of Care, Resumption of Care ...

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Clinical Documentation Review information

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How much do clinical documentation review jobs pay per hour?

As of Sep 9, 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?

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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 Specialist

Chicago, IL • On-site

Clarity Partners LLC
See more jobs at Clarity Partners LLCexternal

$50K - $65K/yr

Full-time

Re-posted 19 days ago

Job description

Voted one of Chicago's Best Places to Work by the Chicago Tribune for the ninth year in a row, Clarity Partners is hiring!
Clarity Partners is seeking a Clinical Documentation Specialist to support a large scale client facing project. In this role, you will work under limited direction and according to clinical documentation guidelines and established policies and procedures to improve the overall quality and completeness of clinical documentation in the legal medical record. You will facilitate necessary documentation through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of severity of illness/risk of mortality (SOI/ROM) for the level of service rendered to all patients. This position plays a critical role in ensuring the accuracy of clinical documentation and supports appropriate coding and billing for services provided. This position will report in a remote setting.
Responsibilities
  • Facilitate necessary documentation in the medical record through extensive interaction with physicians, HIM, and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients.
  • Educate physicians regarding clinical documentation needs, changes to clinical documentation guidelines, and coding and reimbursement opportunities on an ongoing basis.
  • Apply knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities.
  • Perform acute care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses, obtaining missing information via a query when necessary.

Requirements
Requirements
  • At least one of the following: license to practice as a Registered Nurse preferred (any state); or credentialed as an RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician), or CCS (Certified Coding Specialist).
  • 1 year of Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience required.
  • CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required.
  • Experience with concurrent inpatient facility coding/clinical documentation improvement required.
  • Experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation, obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided.

Clarity is committed to fair and equitable compensation practices. For the Clinical Documentation Specialist, the base salary pay range is $50,000 to $65,000. The range represents a good faith estimate that Clarity reasonably expects to pay for this job at the time of posting. Compensation will depend upon an individual's skills, experience, qualifications, location, and other relevant factors. The salary pay range is subject to change and may be modified at any time.

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