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Clinical Documentation Reviewer Jobs (NOW HIRING)

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 ...

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How much do clinical documentation reviewer jobs pay per year?

As of Aug 15, 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?

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 become a clinical documentation reviewer?

To become a clinical documentation reviewer, candidates typically need a healthcare-related degree such as nursing, health information management, or a related field, along with experience in medical coding, billing, or clinical documentation. Certification in medical coding or health information management, like CPC or RHIT, can enhance job prospects. Strong attention to detail, knowledge of medical terminology, and familiarity with electronic health record systems are also important.

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 coding, billing, and clinical guidelines to support proper reimbursement and quality care.

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 August 2026, with employment types broken down into 88% Full Time, 6% Part Time, and 6% Contract. Highlights an 89% In-person, and 11% Remote job distribution, with an average salary of $102,290 per year, or $49.2 per hour.

Clinical Documentation Specialist

Northwell Health

Lake Success, NY

$37 - $49.75/hr

Full-time

Re-posted yesterday

Northwell Health rating

7.8

Company rating: 7.8 out of 10

Based on 564 frontline employees who took The Breakroom Quiz

130th of 887 rated healthcare providers

Job description

Job Description

Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers. Generates queries and have follow up discussions with physicians for clarification of ambiguous or conflicting documentation.

Job Responsibility

1.Facilitates clarification of clinical documentation ensuring accuracy and integrity in the medical record.
2.Facilitates appropriate clinical documentation to support diagnosis coding and ensure the appropriate level of service is recorded.
3.Works with physicians on assigned patient care units to clarify clinical documentation in the patient's medical record through a concurrent review process throughout the patient's inpatient stay.  
4.Requests clarification of clinical documentation from the physician(s) on a concurrent basis as needed to ensure documentation is complete and accurate prior to discharge.
5.Ensures the level of service rendered to patients, and the patient's severity of illness is accurately documented and recorded.
6.Follows up on CDI queries as needed to ensure appropriate documentation is recorded in the medical record. 
7.Interacts with physicians as needed to discuss and advise on clinical documentation requirements and provides timely and accurate responses to clinical documentation and coding questions. 
8.Demonstrates knowledge of ICD-10 CM and ICD-10 PCS coding, MS-DRG and APR NY and APR National grouper logic, documentation opportunities, clinical documentation requirements, and compliance to regulatory and facility policies and procedures. 
9.Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
10.Reconciles reviewed cases to update any changes in status, procedures/treatments, and confer with providers to finalize diagnoses. 
11.Educates medical staff on clinical documentation opportunities that impacts the accuracy of the medical record. 
12.Inputs outcome data in the CDI software to be able to track response to queries. Responsible for file maintenance including entry into database for tracking and trending audit results.  Communicate findings of potential or missed diagnoses and the revenue impact that were discovered during the chart audit.
13.Regularly exercises independent judgment on matters of significance within defined procedures todetermine appropriateactions/approaches
14.Understands department,division, corporate strategy and operating objectives, including impacts
15.Normally receives general instructions on routinework, detailed instructions on new projects or assignments
16.Majority of contact is within own function, area, or department and may be customer service oriented
17.Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here but considered related are not essential functions.

Job Qualification

Graduate from an accredited School of Nursing required. Must obtain a
Bachelor of Science in Nursing degree within 5 years of employment date.
Current License to practice as a Registered Professional Nurse in New York
State required, plus specialized certifications as needed. (CCEDS and CCS)
1-3 years of relevant experience, required.


*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

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