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Clinical Documentation Specialist Rn Jobs (NOW HIRING)

TidalHealth

Clinical Documentation Specialist

Salisbury, MD · Hybrid

$34.25 - $46.25/hr

Licensed as a Registered Nurse (RN) in the state of residency * Certified Clinical Document Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) is required. * CCS, RHIT or RHIA ...

TidalHealth

Clinical Documentation Specialist

Salisbury, MD · On-site

$75K - $121K/yr

Licensed as a Registered Nurse (RN) in the state of residency * Certified Clinical Document Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) is required. * CCS, RHIT or RHIA ...

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Clinical Documentation Specialist Rn information

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How much do clinical documentation specialist rn jobs pay per hour?

As of Jul 3, 2026, the average hourly pay for clinical documentation specialist rn 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 the difference between Clinical Documentation Specialist Rn vs Medical Records Coordinator?

AspectClinical Documentation Specialist RnMedical Records Coordinator
CredentialsRN license, clinical experienceHealth information management certification, administrative skills
Work EnvironmentHospitals, healthcare facilities, clinical settingsMedical records departments, healthcare offices
Employer & IndustryHospitals, clinics, healthcare providersHealthcare facilities, insurance companies, clinics
Search & Comparison IntentRoles involving clinical documentation and codingRecords management and data organization

The Clinical Documentation Specialist Rn focuses on improving clinical documentation accuracy, often requiring nursing credentials and clinical experience. In contrast, the Medical Records Coordinator manages patient records, emphasizing administrative and health information skills. Both roles are vital in healthcare but serve different functions within the medical documentation process.

How does a Clinical Documentation Specialist RN typically collaborate with physicians and other healthcare providers?

Clinical Documentation Specialist RNs play a crucial role in ensuring the accuracy and completeness of patient records by working closely with physicians, nurses, and other healthcare providers. They often communicate directly with clinicians to clarify documentation, answer questions, and provide education on best practices for record-keeping. This collaboration helps ensure compliance with regulatory standards and supports accurate coding and billing. Building strong, respectful professional relationships and effective communication skills are essential for success in this collaborative environment.

What is a Clinical Documentation Specialist RN?

A Clinical Documentation Specialist RN is a registered nurse who specializes in reviewing and improving the accuracy and quality of clinical documentation in patient medical records. Their main goal is to ensure that healthcare records reflect the full extent of care provided, which helps with patient care, coding, billing, and regulatory compliance. They often work closely with physicians, coders, and other healthcare staff to clarify documentation and provide education on best practices. This role requires strong clinical knowledge, attention to detail, and familiarity with healthcare regulations.

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

To excel as a Clinical Documentation Specialist RN, you need a deep understanding of clinical care, medical terminology, and coding practices, typically supported by an active RN license and experience in acute care settings. Familiarity with electronic health record (EHR) systems, clinical documentation improvement (CDI) software, and certifications like CCDS (Certified Clinical Documentation Specialist) are highly valued. Outstanding attention to detail, strong analytical thinking, and effective communication skills are essential soft skills for collaborating with physicians and other healthcare staff. These competencies ensure the accuracy and completeness of patient records, which directly impacts patient care quality, compliance, and hospital reimbursement.
More about Clinical Documentation Specialist Rn jobs
What cities are hiring for Clinical Documentation Specialist Rn jobs? Cities with the most Clinical Documentation Specialist Rn job openings:
What states have the most Clinical Documentation Specialist Rn jobs? States with the most job openings for Clinical Documentation Specialist Rn jobs include:
Clinical Documentation Specialist Rn jobs near you
Infographic showing various Clinical Documentation Specialist Rn job openings in the United States as of June 2026, with employment types broken down into 57% Full Time, 41% Part Time, 1% Temporary, and 1% Contract. Highlights an 94% Physical, 2% Hybrid, and 4% Remote job distribution, with an average salary of $81,742 per year, or $39.3 per hour.

Clinical Documentation Specialist

Centers Home

Pompano Beach, FL

$31.50 - $42.50/hr

Full-time

Posted 12 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