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Clinical Documentation Specialist

Medford, MA

$36.25 - $48.75/hr

Clinical Documentation Specialist Department: Quality Improvement Reports To: Sr. Manager, Clinical Documentation FLSA Status: Non-Exempt Position Summary The Clinical Documentation Specialist is a ...

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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 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 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.

More about Clinical Documentation jobs
What cities are hiring for Clinical Documentation jobs? Cities with the most Clinical Documentation job openings:
What are the most commonly searched types of Clinical Documentation jobs? The most popular types of Clinical Documentation jobs are:
What states have the most Clinical Documentation jobs? States with the most job openings for Clinical Documentation jobs include:
Clinical Documentation jobs near you
Infographic showing various Clinical Documentation job openings in the United States as of May 2026, with employment types broken down into 3% As Needed, 76% Full Time, 17% Part Time, and 4% 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 Coordinator

Access Healthcare Staffing & Recruitment

Las Vegas, NV • On-site

Full-time

Medical, Dental, Vision, Retirement, PTO

Posted 21 days ago

Job description

Salary: $39.17 - $60.71 Hourly

Clinical Documentation Coordinator
*THIS POSITION IS NOT REMOTE*
Location: Las Vegas, NV
Employment Type: Full-Time
Work Model: Hybrid after 6-month probationary period

Position Summary

We are seeking a Clinical Documentation Coordinator to support accurate, complete, and compliant clinical documentation within an acute care inpatient setting.

The CDI Specialist will collaborate with physicians, nursing staff, coding professionals, and ancillary departments to ensure documentation reflects the severity of illness, risk of mortality, quality metrics, and reimbursement accuracy.

This position is open to qualified Registered Nurses, International Medical Graduates (Physicians), and Health Information Management professionalswith required CDI certification.

Key Responsibilities

  • Conduct concurrent review of inpatient medical records to ensure accurate and complete clinical documentation
  • Identify documentation opportunities and initiate compliant physician queries
  • Ensure documentation supports appropriate MS-DRG, APR-DRG, and risk adjustment capture
  • Collaborate with Coding, Case Management, and Quality teams
  • Educate providers on documentation best practices and regulatory requirements
  • Monitor and improve key CDI metrics (query rate, response rate, agreement rate, CMI impact)
  • Maintain compliance with CMS and payer guidelines

Minimum Qualifications

All candidates must hold one of the following CDI certifications:

  • Certified Clinical Documentation Specialist (CCDS)
  • Certified Clinical Documentation Specialist-Outpatient (CCDS-O)
  • Certified Document Improvement Practitioner (CDIP)

Registered Nurse Pathway

Education & Experience

  • Graduate of an accredited school of nursing
  • Minimum 3 years of clinical nursing experience
  • Minimum 3 years of Clinical Documentation Improvement experience

Licensure

  • Active, unrestricted Nevada Registered Nurse license

Physician (International Medical Graduate) Pathway

Education & Experience

  • International Medical Graduate (MD)
  • Minimum 3 years acute care clinical experience
  • Minimum 3 years CDI experience

HIM / Coding Pathway

Education & Experience

  • Bachelors degree in Healthcare or related field (or equivalent experience)
  • Minimum 3 years Health Information Management experience in acute inpatient setting
  • Minimum 3 years CDI experience

Required Coding Certification (one of the following):

  • Certified Coding Specialist (CCS)
  • Registered Health Information Technician (RHIT)
  • Registered Health Information Administrator (RHIA)
  • Certified Professional Coder (CPC)
  • Certified Professional Coder-Physician-based (CPC-P)

Why Join Us?

  • Collaborative, team-focused CDI environment
  • Opportunity to impact quality metrics and patient outcomes
  • Competitive compensation based on experience and credentials


Benefits

  • Employer-Paid Pension through Nevada PERS (vested after 5 years)
  • Health, Dental & Vision Insurance employee-only coverage under $20 per paycheck
  • Consolidated Annual Leave (CAL): PTO, holidays (12/year), sick time, and personal leave
  • Extended Illness (Sick) Bank
  • 457 Deferred Compensation Plan
  • Comprehensive Group Health Insurance
  • No Nevada State Income Tax
  • No Social Security (FICA) deduction