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Clinical Documentation Jobs in Indiana (NOW HIRING)

Reid Home Health

RN - SLR

Richmond, IN

$31 - $41.75/hr

RN - Clinical Documentation Integrity Schedule: Day Shift. 40 hours weekly. Monday - Friday, no holidays. Position onsite. About the Position Follows the American Health Information Management ...

Reid Home Health

RN - SLR

Richmond, IN

$31 - $41.75/hr

RN - Clinical Documentation Integrity Schedule: Day Shift. 40 hours weekly. Monday - Friday, no holidays. Position onsite. About the Position Follows the American Health Information Management ...

Ascension Recovery Services

Clinical Director

Muncie, IN

$74.20K - $101.10K/yr

Clinical Director Location: Indiana Treatment Centers - Muncie, IN Target Opening: Late Spring 2026 ... Compliance, Quality & Documentation * Maintain compliance with all state, federal, and ...

Ascension Recovery Services

Clinical Director

Muncie, IN · On-site

$74.20K - $101.10K/yr

Clinical Director Location: Indiana Treatment Centers - Muncie, IN Target Opening: Late Spring 2026 ... Compliance, Quality & Documentation * Maintain compliance with all state, federal, and ...

Ascension Recovery Services

Clinical Director

Columbus, IN · On-site

$68.30K - $93.10K/yr

Clinical Director Location: Indiana Treatment Centers Columbus, IN Status: Full-Time | Exempt ... Compliance, Quality & Documentation * Maintain compliance with all state, federal, and ...

Ascension Recovery Services

Clinical Director

Muncie, IN · On-site

$74.20K - $101.10K/yr

Salary: Clinical Director Location: Indiana Treatment Centers Muncie, IN Target Opening: Late ... Compliance, Quality & Documentation * Maintain compliance with all state, federal, and ...

Ascension Recovery Services

Clinical Director

Columbus, IN · On-site

$68.30K - $93.10K/yr

Clinical Director Location: Indiana Treatment Centers - Columbus, IN Status: Full-Time | Exempt ... Compliance, Quality & Documentation * Maintain compliance with all state, federal, and ...

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Clinical Documentation information

See Indiana salary details

$18

$37

$56

How much do clinical documentation jobs pay per hour?

As of May 28, 2026, the average hourly pay for clinical documentation in Indiana is $37.40, according to ZipRecruiter salary data. Most workers in this role earn between $31.78 and $42.79 per hour, depending on experience, location, and employer.

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

To thrive as a Clinical Documentation Specialist, you need a strong understanding of medical terminology, anatomy, disease processes, and clinical coding, typically supported by a background in healthcare and certifications such as CCDS or CDIP. Familiarity with electronic health record (EHR) systems, coding software, and clinical documentation improvement (CDI) tools is crucial. Attention to detail, analytical thinking, and effective communication with healthcare providers are standout soft skills in this role. These competencies ensure accurate and comprehensive clinical records, which are vital for patient care quality, regulatory compliance, and optimal reimbursement.

What are some common challenges faced by professionals in Clinical Documentation, and how can they be addressed?

One common challenge in Clinical Documentation is ensuring accuracy and completeness while working under tight deadlines. Documentation specialists must interpret complex medical information and maintain compliance with regulatory standards, which can be demanding. Collaborating closely with physicians and other healthcare staff helps clarify ambiguities, and ongoing training keeps professionals updated on coding changes and best practices. Embracing technology, such as electronic health records (EHRs), also streamlines workflows and reduces errors.

What is clinical documentation?

Clinical documentation refers to the process of recording detailed information about a patient's medical history, diagnoses, treatments, and care in a healthcare setting. This documentation is critical for ensuring accurate communication among healthcare providers, supporting quality patient care, and fulfilling legal and billing requirements. Proper clinical documentation also helps in coding for insurance claims and maintaining compliance with healthcare regulations. It typically involves both handwritten and electronic records, and professionals involved may include physicians, nurses, and clinical documentation specialists.

What is the difference between Clinical Documentation vs Medical Records Technician?

AspectClinical DocumentationMedical Records Technician
CertificationsNone required, but certifications like CCDS can be beneficialRegistered Health Information Technician (RHIT) or Certified Medical Records Technician (CMRT)
Work EnvironmentHospitals, clinics, healthcare facilities, often involved in clinical settingsMedical records departments, healthcare facilities, focusing on record management
Primary ResponsibilitiesCreating, managing, and ensuring accuracy of clinical documentation for patient careOrganizing, coding, and maintaining patient health records and data

While both roles involve handling healthcare information, Clinical Documentation focuses on creating and managing detailed clinical records to support patient care and billing, whereas Medical Records Technicians primarily organize and maintain patient records for administrative purposes. Understanding these differences helps healthcare organizations assign the right roles for accurate documentation and record management.

What are the most commonly searched types of Clinical Documentation jobs in Indiana? The most popular types of Clinical Documentation jobs in Indiana are:
Clinical Documentation jobs near you
Infographic showing various Clinical Documentation job openings in Indiana as of May 2026, with employment types broken down into 3% As Needed, 75% Full Time, 18% Part Time, and 4% Contract. Highlights an 94% Physical, 2% Hybrid, and 4% Remote job distribution, with an average salary of $77,783 per year, or $37.4 per hour.
Clinical Documentation Specialist

Clinical Documentation Specialist

Greene County General Hospital

Linton, IN • On-site

$31.75 - $42.75/hr

Full-time

Posted 28 days ago

Job description

The Clinical Documentation Specialist serves as the hospital’s subject matter expert for clinical documentation integrity, electronic health record (EHR) optimization, and clinical workflow design. This role bridges clinical operations, quality, regulatory compliance, health information management, and information technology to ensure accurate, complete, compliant, and efficient documentation within the EHR. The Specialist collaborates with physicians, nursing, ancillary departments, IT, and external vendors to optimize system functionality, support CMS and TJC requirements, and maintain clinical documentation integrity.

Essential Duties and Responsibilities:

  • Conduct concurrent and retrospective documentation review to ensure completeness, regulatory compliance, and accurate reflection of patient severity and services rendered.
  • Communicate documentation clarification opportunities to providers and collaborate with HIM on coding and DRG alignment.
  • Monitor provider documentation compliance, including unsigned orders and required regulatory elements.
  • Educate clinical staff on documentation standards and regulatory updates.
  • Serve as the primary clinical lead for EHR build, maintenance, and workflow design.
  • Develop, test, and maintain clinical documentation tools, forms, order sets, templates, and reporting structures.
  • Troubleshoot system issues and coordinate resolution with IT and vendor partners.
  • Manage user access, security roles, and clinical system configurations
  • Provide onboarding and ongoing training for clinical users.
  • Support and monitor performance for Promoting Interoperability, eCQMs, MIPS, and other CMS reporting programs.
  • Support patient portal functionality and interoperability initiatives.
  • Coordinate with external entities and vendors to maintain accurate provider mapping and electronic data exchange.
  • Open and manage vendor support tickets as needed.
  • Participate in regulatory readiness, quality improvement, and patient safety initiatives.
  • Serve as a liaison between clinical departments, quality, HIM, and IT to ensure alignment of documentation and workflow practices.
  • Support a culture of safety through proactive monitoring of documentation and workflow risks.
  • Support CareWeb access and troubleshoot user issues.
  • Build and maintain ad hoc report templates
  • Ensures patient care environments and practices support exemplary, safe, and high-quality care of patients and families.
  • Ensures that workplace environments are safe and that strategies are in place to prevent physical and psychological harm.
  • Demonstrates clear ownership of workplace and patient safety.
  • Reports mistakes, near misses, adverse events and quality and safety concerns.
  • Develops and implements safety and quality plans that support exemplary workplace and care practices, while also supporting a culture of safety.
  • Other duties as may be assigned.

Job Requirements

Education: Associate or Bachelor’s degree in Nursing, Healthcare Administration, Health Information Management, Clinical Informatics, or related field; or equivalent combination of education and experience.

Experience: Minimum three (3) years of acute care clinical experience required. Experience in clinical documentation improvement, quality management, informatics, utilization review, or coding preferred. Experience with hospital-based EHR systems strongly preferred.

  • Advanced proficiency in EHR systems and reporting tools.
  • Strong analytical, problem-solving, and communication skills.
  • Ability to balance regulatory compliance, reimbursement integrity, workflow efficiency, and patient safety.

Physical Requirements: Frequent sitting, standing, and walking. Ability to lift up to 25 pounds unassisted. Adequate vision and hearing for effective communication and computer-based work.

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