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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 ...

TidalHealth

Clinical Documentation Specialist

Salisbury, MD · Hybrid

$34.25 - $46.25/hr

Clinical Documentation Specialist Position Summary The Clinical Documentation Integrity (CDI ... The role involves thorough chart reviews and collaboration with providers, nurses, consultants, and ...

Zotec Partners

Clinical Documentation Manager

As a Clinical Documentation Manager , you will perform concurrent and retrospective review of the medical record, provider education, and educate clinicians to ensure the documentation of all ...

Guidehouse

Clinical Documentation Specialist

$61K - $101K/yr

Conducts daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge for accurate ...

Quorum Health

Clinical Documentation Specialist

Brentwood, TN · On-site

$33 - $44.25/hr

Provides clinically based, concurrent and retrospective reviews of inpatient medical records. Ensures documentation accurately reflects quality of care, severity of illness and risk of mortality to ...

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Clinical Documentation Reviewer information

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How much do clinical documentation reviewer jobs pay per year?

As of Aug 6, 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 1% As Needed, 70% Full Time, 23% Part Time, 1% Temporary, 4% Contract, and 1% Nights. Highlights an 94% Physical, 2% Hybrid, and 4% Remote job distribution, with an average salary of $102,290 per year, or $49.2 per hour.

Clinical Documentation Specialist

Centers Home

Pompano Beach, FL

$31.50 - $42.50/hr

Full-time

Re-posted 17 days ago

Job description

Job Title: Clinical Documentation Specialist (RN/LPN) – Full Time
Location: On-site – Staten Island, NY | Valley Stream, NY | Margate, FL
Schedule: Monday to Friday, 9:00 AM – 5:00 PM
Department: Clinical
Reports To: VP of Clinical Operations
Company: Revival Home Health Care

Position Summary:

Revival Home Health Care, a certified and respected home health agency, is seeking a dedicated Clinical Documentation Specialist (RN or LPN) to join our Clinical team. This is a full-time, on-site role responsible for auditing and reviewing patient charts to ensure compliance with all New York State Department of Health (DOH) regulations and standards, as well as internal clinical documentation policies and procedures.

Key Responsibilities:

Conduct detailed audits of clinical documentation for accuracy, completeness, and regulatory compliance

Review and validate OASIS assessments, visit notes, care plans, and physician orders

Ensure appropriate and accurate ICD-10 coding aligned with current home health guidelines

Identify documentation trends and collaborate with clinical staff to provide training and feedback

Support internal quality assurance and performance improvement initiatives

Generate audit reports and present findings to leadership for follow-up actions

Participate in team meetings to support clinical quality improvement efforts

Maintain up-to-date knowledge of DOH, CMS, and other relevant regulatory updates

Qualifications:

Active RN or LPN license in New York State or Florida

Minimum of 1 year of home health care experience

Strong knowledge of clinical documentation practices and standards

OASIS and ICD-10 coding experience strongly preferred

Exceptional attention to detail and analytical skills

Strong communication and interpersonal abilities

Proficiency in EMR systems and Microsoft Office Suite

Why Join Revival Home Health Care?

Join a mission-focused team dedicated to excellence in patient care

Work in a supportive and collaborative clinical environment

Gain professional development opportunities

Enjoy a competitive salary and full benefits package

Apply