ZipRecruiter

Log In

1

Clinical Documentation Specialist Rn Jobs (NOW HIRING)

CentraCare

Clinical Documentation Nurse

Saint Cloud, MN · Remote

$87K - $130K/yr

Current Registered Nurse (RN) licensure in the State of Minnesota required * Minimum of 3 years ... Certified Clinical Documentation Specialist National Certification as Clinical Documentation ...

New

next page

Showing results 1-20

All JobsClinical Documentation Specialist Rn Jobs

Clinical Documentation Specialist Rn information

See salary details

$18

$39

$59

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

Clinical Documentation Specialist

CareWell Health

East Orange, NJ • On-site

$36.25 - $48.75/hr

Full-time

Posted 17 days ago

Job description

Job Summary:
Responsible for improving the overall quality, accuracy and completeness of clinical documentation within the medical record. Conducts concurrent, retrospective, and post-bill comprehensive reviews of the clinical documentation. Facilitates updates to the clinical documentation through interactions with physicians, nursing, HIM and coding staff and other peer to peer interactions, to ensure appropriate reimbursement for the level of service rendered to all patients with a DRG based payer. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. Educate physicians and providers on an ongoing basis through daily conversations, communication, and presentations.
Essential Functions:
  • Conducts concurrent, retrospective and post-bill comprehensive reviews of the clinical documentation.
  • Facilitates modifications updates to the clinical documentation to ensure appropriate reimbursement for the level of service provided to all patients with a DRG based payer.
  • Demonstrates knowledge of DRG payer issues, documentation opportunities, and clinical documentation requirements.
  • Improves the overall quality and completeness of clinical documentation by performing detailed concurrent, retrospective and post-bill reviews of the clinical documentation for quality improvement and financial impact on Inpatients.
  • Improves the entire documentation for Severity of Illness, Risk of Mortality, Acuity and to capture Comorbid and Major Comorbid conditions
  • Ensures details are elaborated on within the physician queries to ensure they are compliant and complete by including clinical indicators, treatment and documentation.
  • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and organizational outcomes.
  • Collaborates with Case Management, and Nursing to ensure the level of care provided to the patients is accurately reflected in the documentation and meets quality and compliance goals set forth by the facility.
  • Places timely queries into the Electronic Medical Record to capture any changes in status, procedures/ treatments as set forth by CareWell Health's Policies and Procedures.
  • Follows up on unanswered queries, in a timely manner by contacting the provider and conferring with physician to finalize diagnoses.
  • Educates all relevant internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
  • Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's medical record.
  • Identify gaps, inconsistencies, or omissions in documentation that impact coding, severity of illness (SOI), risk of mortality (ROM), and quality metrics.
  • Act as a liaison between clinical and coding teams to ensure consistent documentation and coding practices.
  • Participate in quality improvement initiatives, audits, and committee work.
  • Stay current with CDI best practices, coding guidelines (ICD-10, MS-DRG, APR-DRG), and regulatory changes (CMS, OIG, etc.).
  • Must be computer savvy.
  • Assists with special projects.
  • Provides CDI Metric Reporting and program updates to the Utilization Review Committee, when necessary.
  • Advises CDI Manager and/or Director of HIM with immediate challenges that have a negative impact on the program's functions.
  • Performs other duties as assigned.

Other Duties:
  • Strong critical thinking skills, able to assess, evaluate and teach. Flexible with a working knowledge of adult medicine. Sight and hearing.
  • Requires excellent observation skills, analytical thinking, problem solving, good strong verbal and written communication skills. Professional, team player, able to communicate well with all levels of staff. Strong interpersonal skills, pleasing personality, positive demeanor.
  • Performs other duties as assigned.

Minimum Education/Certifications:
Certified Coding Specialist (CCS), required. Certified Clinical Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS), required or obtained within one (1) year of employment. Registered Nurse (RN), MD, DO, or ECFMG Certification, required.
Minimum Work Experience:
Two (2) years of CD experience in an acute care hospital and / or 2 (two) years of ICD-10 CM coding experience.

Apply