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Clinical Documentation Jobs in Nevada (NOW HIRING)

Fusion HCR

Clinical Documentation Coordinator

Las Vegas, NV · On-site

$33.50 - $45/hr

Facilitates modifications to clinical documentation through extensive interactions with physicians, nursing staff, other members of the health care team and Health Information Management (HIM) coding ...

Fusion HCR

Clinical Documentation Manager

Las Vegas, NV · On-site

$33.50 - $45/hr

Direct Hire - Clinical Documentation Manager, this is an onsite opportunity, working with our client in Acute Healthcare. Our client, a large healthcare organization, is seeking an experienced ...

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How much do clinical documentation jobs pay per hour?

As of May 28, 2026, the average hourly pay for clinical documentation in Nevada is $40.02, according to ZipRecruiter salary data. Most workers in this role earn between $34.04 and $45.77 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 Nevada? The most popular types of Clinical Documentation jobs in Nevada are:
Clinical Documentation jobs near you

Clinical Documentation Coordinator

Fusion HCR

Las Vegas, NV • On-site

$33.50 - $45/hr

Full-time

This job post has expired today. Applications are no longer accepted.

Job description

Position Summary:
Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interactions with physicians, nursing staff, other members of the health care team and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer.
 

Education/Experience: 

Option 1: Graduation from an accredited school of nursing and three (3) years of clinical nursing experience and three (3) years clinical documentation improvement experience. 

Option 2: Physician graduate International MD with three (3) years of acute care experience and three (3) years Clinical Documentation Improvement (CDI) experience. 

Option 3: Equivalent to a Bachelor's degree in Healthcare and three (3) years Health Information Management in an acute care hospital inpatient experience and three (3) years Clinical Documentation Improvement (CDI) experience.

Licensing/Certification Requirements:

Option 1: Valid license by the State of Nevada to practice as a Registered Nurse and one of the following, Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O) or Certified Document Improvement Practitioner (CDIP). 

Option 2: An international medical graduate degree and one of the following: Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O). 

Option 3: Certification in one of the following: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), issued by the American Health Information Management Association, Certified Professional Coder (CPC), Certified Professional Coder-Physician-based (CPC-P), AND one of the following: Certified Document Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Clinical Documentation Specialist-Outpatient (CCDS-O).


Knowledge of:
Medicare reimbursement system and coding structures; hospital policies and procedures; Joint Commission Accredited Health care Organizations standards, state statutes governing hospital services and health care, Medicare/Medicaid guidelines and other relevant regulations and standards; clinical medical and nursing procedures; disease processes; department and hospital safety practices and principles; patient rights; age specific patient care practices; infection control policies and practices; department and hospital emergency response policies and procedures.

Skill in:
Working effectively under pressure; holding in complete confidence all information acquired from medical records and physicians; interpreting patient charts to determine whether care given was appropriate and properly documented; interpreting regulations and standards for others; writing reports, meeting minutes and other technical documents; analyzing statistical and other quantitative data; critical thinking; conflict management; dealing with departmental issues involving self or other employees in professional, forthright and impartial manner; applying investigative and interviewing techniques; using a computer and a variety of software applications; communicating with a wide variety and establishing interpersonal relationships to interact effectively with co-workers, supervisor, staff in other work units and exchange or convey information.