ZipRecruiter

Log In

1

Clinical Documentation Jobs in Indiana (NOW HIRING)

Hickory Recovery

Clinical Director

Indianapolis, IN · On-site

$90K - $100K/yr

Clinical Documentation & Quality Assurance * Audits the EMR for all clients to ensure timely and accurate documentation * Audits therapy notes daily and provides feedback as needed * Conducts routine ...

next page

Showing results 1-20

All JobsClinical Documentation JobsClinical Documentation Jobs in Indiana

Clinical Documentation information

See Indiana salary details

$18

$37

$56

How much do clinical documentation jobs pay per hour?

As of Jul 30, 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 does a clinical documentation do?

A clinical documentation specialist reviews and ensures the accuracy, completeness, and clarity of medical records and documentation. They work closely with healthcare providers to improve documentation quality, which supports proper patient care, billing, and compliance with regulations. Proficiency in medical terminology and electronic health record systems is essential for this role.

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 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.

Is clinical documentation a good career?

Clinical documentation is a viable career that involves creating accurate medical records for healthcare providers, requiring attention to detail and knowledge of medical terminology. It offers opportunities for remote work, certification options, and steady demand due to healthcare industry needs. Success in this field often depends on strong communication skills and familiarity with electronic health record systems.

How to get into CDI with no experience?

To enter clinical documentation improvement (CDI) roles with no experience, candidates should focus on gaining knowledge of medical terminology, coding, and healthcare documentation through online courses or certifications such as Certified Clinical Documentation Specialist (CCDS). Entry-level positions often require strong attention to detail and good communication skills, and some employers may offer on-the-job training for new hires without prior CDI experience.

Is it hard to get a CDI job?

Clinical Documentation Improvement (CDI) jobs can be competitive, but having relevant certifications such as the Certified Clinical Documentation Specialist (CCDS) and strong clinical or coding experience can improve your chances. Entry-level positions may require some experience or training, but many employers value specialized knowledge and attention to detail in this field.
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 July 2026, with employment types broken down into 2% As Needed, 76% Full Time, 14% Part Time, and 8% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution, with an average salary of $77,783 per year, or $37.4 per hour.

Epic Implementation Clinical Documentation Specialist

Greene County General Hospital

Linton, IN • On-site

Full-time

Posted 8 days ago

Job description

The Epic Implementation/Clinical Documentation Specialist serves as the hospital's subject matter expert for clinical documentation integrity, Epic electronic health record (EHR) implementation, 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 provides on-site clinical leadership for Epic implementation, workflow validation, user readiness, go-live support, and post-implementation optimization. This is an on-site position.
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, regulatory updates, and EHR-related workflow changes.
  • Serve as the primary clinical lead for Epic EHR implementation, clinical workflow design, validation, optimization, and ongoing support.
  • Translate clinical workflows and operational needs into Epic build requests, workflow specifications, testing scenarios, and training needs in collaboration with IT, operational leaders, and vendor partners.
  • Lead or support workflow mapping, readiness assessments, user acceptance testing, integrated testing, issue tracking, go-live preparation, go-live support, and post-live optimization activities.
  • Collaborate with clinical leaders, providers, super users, and frontline staff to identify workflow risks, adoption barriers, documentation gaps, and patient safety concerns related to Epic implementation and use.
  • Develop, test, validate, and maintain clinical documentation tools, forms, order sets, templates, smart phrases, reports, and other EHR documentation structures as assigned.
  • Troubleshoot system issues, prioritize clinical risks, coordinate resolution with IT and vendor partners, and open or manage support tickets as needed.
  • Support user access, security role review, clinical system configurations, and workflow-specific permissions in collaboration with IT and organizational leadership.
  • Provide onboarding, coaching, just-in-time education, and ongoing training for clinical users, including providers, nursing, ancillary departments, and other clinical staff.
  • Support patient portal functionality, interoperability initiatives, provider mapping, electronic data exchange, and communication with external entities or vendors.
  • Participate in regulatory readiness, quality improvement, compliance, and patient safety initiatives related to clinical documentation and EHR workflows.
  • Serve as a liaison between clinical departments, quality, HIM, IT, and vender partners 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 as assigned.
  • 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, coding, EHR implementation, or clinical workflow optimization preferred. Experience with Epic or hospital-based EHR systems strongly preferred.
  • Advanced proficiency in EHR systems, clinical documentation workflows, and reporting tools.
  • Ability to support on-site implementation activities, including workflow review, training, go-live readiness, and direct clinical user support.
  • Strong analytical, problem-solving, and communication skills.
  • Ability to balance regulatory compliance, reimbursement integrity, workflow efficiency, and patient safety.
  • Availability to provide on-site support during implementation, go-live, post-live stabilization, and other operational needs as assigned.

Work Environment: This position is an on-site role located at Greene County General Hospital or assigned hospital-owned locations. The position is not remote and requires in-person presence to support clinical workflows, staff education, implementation activities, go-live support, troubleshooting, and operational needs.
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.

Apply