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Clinical Documentation Reviewer Jobs (NOW HIRING)

Ascension

Clinical Documentation Auditor

Austin, TX · Remote

$96K - $134K/yr

Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing ...

Ascension

Clinical Documentation Auditor

Austin, TX · Remote

$96K/yr

Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing ...

FMOLHS

Clinical Documentation Specialist

Baton Rouge, LA · On-site

$33.25 - $45/hr

The Clinical Documentation Specialist (CDS) improves the accuracy and completeness of clinical ... Documents CDI review findings, following processes and guidelines. d. Submits queries to physicians ...

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Clinical Documentation Reviewer information

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$125K

How much do clinical documentation reviewer jobs pay per year?

As of Jun 17, 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.

How to get into CDI with no experience?

To become a Clinical Documentation Reviewer (CDI) with no experience, candidates should focus on gaining knowledge of medical terminology, coding, and documentation standards through online courses or certifications such as AHIMA's Certified Documentation Improvement Practitioner (CDIP). Entry-level roles may require strong attention to detail, good communication skills, and familiarity with electronic health records (EHR) systems, and some employers offer on-the-job training for new hires.

Is CDI a good career?

Clinical Documentation Reviewer (CDI) is a growing healthcare role that involves reviewing medical records for accuracy and completeness to support proper coding and billing. It requires strong attention to detail, knowledge of medical terminology, and often certification such as CCDS. The role offers opportunities for career advancement and typically features a stable work environment with regular hours.

What is a clinical documentation reviewer?

A clinical documentation reviewer evaluates medical records and documentation to ensure accuracy, completeness, and compliance with healthcare standards. They often work with electronic health record systems and may require knowledge of medical coding and certifications such as CCS or CPC.

How much does it cost to take the CDI exam?

The Certified Documentation Improvement Practitioner (CDI) exam typically costs around $300 to $400, depending on the certifying organization and membership status. Fees may include registration, study materials, and exam administration, and candidates should verify current costs with the certifying body before registering.

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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What cities are hiring for Clinical Documentation Reviewer jobs? Cities with the most Clinical Documentation Reviewer job openings:
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What job categories do people searching Clinical Documentation Reviewer jobs look for? The top searched job categories for Clinical Documentation Reviewer jobs are:
Clinical Documentation Reviewer jobs near you
Infographic showing various Clinical Documentation Reviewer job openings in the United States as of June 2026, with employment types broken down into 100% Full Time. Highlights an 100% In-person job distribution, with an average salary of $102,290 per year, or $49.2 per hour.

IBHS Clinical Documentation Reviewer

Dunbar Wellness Group

Philadelphia, PA • On-site

$25 - $29/hr

Full-time

PTO

Posted 20 hours ago

Job description

Job Type: Full-Time (W2)

Location: Philadelphia, PA (In-person)

Schedule: Monday – Friday (8:30 AM- 5 PM)


Our Mission

Dunbar Wellness Group, Inc. was founded by a group of dedicated community-based partners. Our mission is to integrate a holistic treatment approach that includes understanding community ecology and social advocacy for children and families in Philadelphia.

In addition, we promote quality therapeutic services that are resiliency and recovery-focused, trauma-informed, and culturally sensitive to the unique needs of urban children and families.

Position Summary

Reporting to the IBHS Clinical Director, the IBHS Clinical Documentation Reviewer is responsible for reviewing and monitoring clinical documentation completed by Behavioral Consultants (BC), Mobile Therapists (MT), and Behavioral Health Technicians (BHT) to ensure compliance with IBHS regulations, agency policies, and payer requirements. The IBHS Clinical Documentation Reviewer will ensure that progress notes are accurate, clinically appropriate, complete, and submitted within required timelines.

The IBHS Clinical Documentation Reviewer supports quality assurance efforts by identifying documentation deficiencies, providing corrective feedback, and promoting high standards of clinical documentation across the IBHS program.

Essential Duties & Responsibilities

Documentation Review

  • The IBHS Clinical Documentation Reviewer will review BC, MT, and BHT progress notes for accuracy, completeness, and compliance.
  • Ensure documentation reflects medical necessity, individualized interventions, and measurable progress toward treatment goals.
  • Verify that notes include objective observations, appropriate clinical language, and behaviorally specific interventions.
  • Monitor documentation for timeliness and completion according to agency and payer requirements.
  • Identify missing signatures, incomplete sections, inconsistencies, or compliance concerns.
  • Ensure interventions documented align with approved treatment plans and service authorizations.

Quality Assurance & Compliance

  • The IBHS Clinical Documentation Reviewer will conduct routine chart audits and documentation quality reviews.
  • Ensure compliance with:
    • Pennsylvania IBHS regulations
    • Medicaid and managed care standards
    • HIPAA confidentiality requirements
    • Agency documentation policies
  • Maintain tracking systems for documentation compliance and corrective actions.
  • Assist with preparation for audits, licensing reviews, and payer requests.

Staff Support & Feedback

  • The IBHS Clinical Documentation Reviewer will provide constructive feedback and recommendations to BCs, MTs, and BHTs regarding documentation improvements.
  • Collaborate with supervisors and clinical leadership to address recurring documentation issues.
  • Support staff training related to clinical documentation standards and best practices.
  • Communicate documentation deadlines and compliance expectations to staff as needed.

Qualifications

  • Master’s degree in Counseling, Social Work, Psychology, Human Services, or related field required.
  • Experience working within IBHS, behavioral health, or children’s mental health services preferred.
  • Strong understanding of clinical documentation standards and behavioral health terminology.
  • Knowledge of IBHS regulations and medical necessity criteria preferred.
  • Excellent written communication, organization, and attention to detail.
  • Ability to work independently and meet deadlines.
  • Proficiency with electronic health records (EHR) systems and Microsoft Office.

Preferred Skills

  • Experience reviewing progress notes or conducting quality assurance audits.
  • Strong analytical and problem-solving skills.
  • Ability to provide professional and supportive feedback to staff.
  • Strong time management and organizational abilities.

Work Environment

  • In-person, office-based setting.
  • Frequent computer and documentation review work.
  • Collaboration with clinical and administrative teams.
  • Fast-paced behavioral health environment requiring professionalism and adaptability.

Benefits

  • Competitive salary
  • Paid time off
  • Professional development opportunities
  • Supportive team culture

Equal Opportunity Employer

Dunbar Wellness Group is an Equal Opportunity Employer committed to fostering an inclusive and supportive workplace for all employees.