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Clinical Documentation Reviewer Jobs (NOW HIRING)

24-MAG LLC

$60 - $90/hr

About the job Remote | Clinical Documentation Review Specialist - $60-$90/hour We are sharing a ... reviewer, or similar documentation-heavy healthcare professional * Experience with one or more ...

The University of Miami

$32.25 - $43.25/hr

The Clinical Documentation Integrity (CDI) Second Level Reviewer performs high-level, complex, secondary case reviews to facilitate and obtain appropriate provider documentation for clinical ...

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How much do clinical documentation reviewer jobs pay per year?

As of May 28, 2026, the average yearly pay for clinical documentation reviewer in the United States is $102,290.00, according to ZipRecruiter salary data. Most workers in this role earn between $94,000.00 and $109,500.00 per year, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Clinical Documentation Reviewer, and why are they important?

To thrive as a Clinical Documentation Reviewer, you need a thorough understanding of medical terminology, clinical workflows, and healthcare regulations, often supported by a background in nursing, HIM, or coding certification (such as RHIA, CCS, or CCDS). Familiarity with electronic health record (EHR) systems, clinical documentation improvement (CDI) software, and coding tools is typically required. Attention to detail, critical thinking, and strong written and verbal communication skills are essential for success in this role. These skills ensure accurate and compliant documentation, which supports optimal patient care, appropriate reimbursement, and regulatory adherence.

What are the most common challenges Clinical Documentation Reviewers face when ensuring documentation accuracy?

Clinical Documentation Reviewers often encounter challenges such as incomplete or ambiguous provider notes, varying documentation styles among clinicians, and tight deadlines for reviewing large volumes of records. Balancing the need for thoroughness with efficiency is key, as is maintaining up-to-date knowledge of regulatory and compliance standards. Effective communication with healthcare providers is essential to clarify documentation and ensure records accurately reflect patient care.

What does a Clinical Documentation Reviewer do?

A Clinical Documentation Reviewer is responsible for evaluating and analyzing medical records to ensure that the documentation accurately reflects the care provided and meets regulatory, legal, and billing requirements. They work closely with healthcare providers to clarify ambiguous or incomplete documentation and to improve the quality of patient records. Their role is crucial in ensuring proper coding, billing, and compliance with healthcare standards, which ultimately supports patient care and institutional integrity.
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Clinical Documentation Reviewer jobs near you
Infographic showing various Clinical Documentation Reviewer job openings in the United States as of May 2026, with employment types broken down into 84% Full Time, 8% Part Time, and 8% Contract. Highlights an 73% In-person, 4% Hybrid, and 23% Remote job distribution, with an average salary of $102,290 per year, or $49.2 per hour.
Clinical Documentation Specialist

Clinical Documentation Specialist

Prairie Lakes Healthcare System

Watertown, SD • On-site

$33 - $44.50/hr

Full-time, Part-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted yesterday

Prairie Lakes Healthcare System rating

4.8

Company rating: 4.8 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

Job description

Clinical Documentation Specialist
Job Summary
Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones
Position Summary
On-site presence in Watertown, SD is required during the first year. This full-time position has the option to be Remote, On-site (Watertown, SD), or Hybrid after the first year.
The Clinical Documentation Specialist (CDS) initiates and performs concurrent documentation review of inpatient records to identify opportunities for clarification of conditions, diagnoses, and procedures when incomplete, conflicting, or nonspecific documentation exists. This review supports accurate capture of clinical severity, level of service, medical necessity, and appropriate reimbursement through the physician query process.
Key Responsibilities
  • Communicates with providers, nursing staff, case managers, coders, and other members of the healthcare team to facilitate complete, accurate, and compliant clinical documentation in the inpatient medical record.
  • Serves as a resource to providers by linking clinical documentation requirements, coding guidelines, and medical terminology to improve the accuracy and completeness of final code assignment.
  • Works collaboratively with the coding department in concurrent review of the inpatient medical record to support appropriate diagnosis related group (DRG) assignment and documentation integrity.
  • Reviews clinical documentation issues with coding staff to identify missed opportunities related to documentation specificity, coding guidelines, and reimbursement, and helps prevent future missed opportunities through education and process improvement.
  • Demonstrates knowledge of clinical documentation standards, coding guidelines, DRGs, medical necessity requirements, and payer regulations, and provides clarification and education to providers and internal customers as needed.
  • Monitors and evaluates the effectiveness of clinical documentation improvement efforts and concurrent review outcomes at designated intervals.
  • Develops, analyzes, and presents reports on documentation review findings, audit results, recommendations, and outcomes to appropriate departments and committees at designated intervals.
  • Maintains accurate and organized records of review activities, findings, queries, and outcomes in accordance with departmental, regulatory, and compliance requirements.
  • Acts as a consultant to coding staff when additional information or documentation is needed to support correct code assignment.
  • Facilitates collaboration among providers, coders, case managers, and ancillary/support departments to improve documentation practices, support quality outcomes, and reduce duplication and variation.

Qualifications
Education and/or Experience-
Bachelor's degree in nursing required. Graduate from a nationally accredited nursing program preferred. Three years of recent clinical nursing experience required. Experience in case management, utilization management, and/or coding preferred.
Certificates, Licenses, Registrations-
Currently holds an unencumbered RN license in the State of South Dakota, or is eligible for current licensure in the State of South Dakota, and/or possesses multistate licensure if practicing in a Nurse Licensure Compact state. Maintains required department-specific competencies and certifications. Certification as a Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred.
Benefits
Prairie Lakes Healthcare System offers comprehensive benefits for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance.
Additional benefits for those qualifying include:
Flexible Spending Account
Employee Assistance Program for mental health
Education Loan Program
Community discounts including the Prairie Lakes Wellness Center
Prairie Lakes Healthcare System has a Drug Free Workplace Policy. An accepted offer will require positive reference checks and pre-employment background screening as a condition of employment.

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