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Clinical Documentation Jobs in Indiana (NOW HIRING)

HHC

Clinical Documentation Specialist

Indianapolis, IN · On-site

$33.25 - $44.75/hr

The CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient being ...

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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 Aug 20, 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 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 are the key skills and qualifications needed to thrive as a clinical documentation specialist?

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 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 August 2026, with employment types broken down into 2% As Needed, 71% Full Time, 22% Part Time, 4% Contract, and 1% Nights. Highlights an 93% Physical, 2% Hybrid, and 5% Remote job distribution, with an average salary of $77,783 per year, or $37.4 per hour.

Clinical Documentation Specialist

Health & Hospital Corporation of Marion County

Indianapolis, IN • On-site

$33.25 - $44.75/hr

Full-time

This job post has expired 1 day ago. Applications are no longer accepted.

Job description

Division:Eskenazi Health
Sub-Division: Hospital
Req ID: 26541
Schedule: Full Time
Shift: Days
Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis.
FLSA Status
Exempt
Job Role Summary
The goal of the CDI Program is to clarify ambiguous, conflicting or incomplete documentation. The CDI professional works to facilitate the overall quality and completeness of clinical documentation to accurately represent the severity, acuity and risk of mortality profile of the patient being treated. The CDI professional achieves these goals through careful review of all of the information and documentation available concurrently through the patient's stay. Focused communication with the treating clinical professionals (i.e., queries) will be utilized to obtain improvements in documentation.
Essential Functions and Responsibilities
  • Formulates and submits letters of appeal; creates an effective appeal utilizing relevant and effective clinical documentation from the medical record supported by current industry clinical guidelines, evidence based medicine, community and national medical management standards and protocols
  • Performs accurate and timely concurrent clinical documentation reviews (POA, PSI,ROM, SOI and missing HCC) in an effort to capture the appropriate physician documentation that will result in accurate ICD-10 coding and DRG assignment that best reflects severity of illness and resource utilization
  • Provides ongoing support and consultation to improve the overall quality of medical record documentation; serves as a clinical resource consultant to the HIM coding staff when coders require clinical decision-making and clinical interpretation to determine appropriate code assignment
  • Develops teaching strategies and methodologies to improve program outcomes
  • Provides primary clinical input into the ongoing planning and development of the Clinical Documentation Management Program (CDMP) in order to support and enhance multidisciplinary performance improvement initiatives; facilitates interaction with medical staff and HIM coding staff to provide collaborative link between departments to promote accurate and complete physician documentation
  • Identifies educational needs of medical staff, health team members and HIM coding staff; plans and implements formal/informal introductory and ongoing orientation and training for multidisciplinary staff
  • Maintains a strong knowledge of DRG methodology, Severity of Illness/ Risk of Mortality statistics and Coding Clinic guidelines
  • Coordinates/collaborates with relevant facility departments (Case Management, Quality, HIM, Revenue Services, etc.) as clinical reviews are performed
  • Participates in federal and state funded audit activity from appeal to legal proceedings (if needed) and maintains documentation of activity
  • Assists with data analysis and summaries; performs mortality reviews in coordination with the Quality department

Job Requirements
  • Indiana licensed Registered Nurse (RN) required
  • Five years of strong and varied clinical experience in an acute care setting required
  • Recent hospital experience, preferably ICU, CCU or strong Med/Surg preferred
  • Knowledge of CMS Regulations
  • Proficient in PC use, Microsoft applications and working knowledge of hospital department computer systems

Knowledge, Skills & Abilities
  • Knowledge of regulatory requirements for appropriateness of admission
  • Knowledge of Observation and Inpatient medical necessity
  • Knowledge of POA/HAC and Core Measures
  • Advanced problem-solving, analytical and critical thinking skills
  • Working knowledge of Joint Commission (JC), Indiana State Department of Health

(ISDH) and Centers for Medicare and Medicaid Services (CMS) regulations as they relate to medical documentation and health information management
  • Ability to work effectively with all levels of the organization, including physicians
  • Knowledge of pathophysiology and disease process
  • Knowledge of clinical documentation management tools and techniques
  • Strong written and verbal communication skills
  • Strong positive attitude; competent interpersonal skills
  • Demonstrated leadership skills and strong organizational skills
  • Ability to work independently; motivated to produce high quality outcomes
  • Working knowledge of various software applications including: EPIC, Excel, and 3M preferred

Accredited by The Joint Commission and named as one of Indiana's best employers by Forbes magazine for two consecutive years and the top hospital in the state for community benefit by the Lown Institute, Eskenazi Health's programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city's primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the first verified adult burn center in Indiana and Sandra Eskenazi Mental Health Center, the first community mental health center in Indiana, just to name a few.

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