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Clinical Documentation Jobs (NOW HIRING)

Bryan Health

Clinical Documentation Specialist

Lincoln, NE · On-site

$33 - $44.25/hr

Ensures the clinical documentation appropriately describes the patient's severity of illness, risk of mortality and reflects the level of service rendered. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the ...

Bryan Health

Clinical Documentation Specialist

Lincoln, NE

$33 - $44.25/hr

Ensures the clinical documentation appropriately describes the patient's severity of illness, risk of mortality and reflects the level of service rendered. PRINCIPAL JOB FUNCTIONS: 1. *Commits to the ...

Ascension

Clinical Documentation Auditor

Austin, TX · Remote

$96K - $134K/yr

Clinical Documentation Integrity Schedule: Full Time | Days | Monday-Friday Salary: $96,208.99-$134,109.89 #LI-AM2 What You Will Do * Assess the accuracy, consistency, and compliance of clinical ...

FMOLHS

Clinical Documentation Specialist

Baton Rouge, LA

$33.25 - $45/hr

The Clinical Documentation Specialist (CDS) improves the accuracy and completeness of clinical documentation in medical records by performing thorough reviews and requesting clarifications from ...

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Clinical Documentation information

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$18

$39

$59

How much do clinical documentation jobs pay per hour?

As of Jun 17, 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 jobs pay 2000 a day?

Clinical documentation roles typically do not pay $2,000 a day; such high daily rates are more common in specialized consulting, executive-level positions, or freelance work in fields like law or finance. Some highly experienced consultants or contractors in niche areas may command such rates, often requiring advanced certifications and extensive expertise. Most clinical documentation jobs offer salaries or hourly wages significantly below this level.

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 (EHR) 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 often offers flexible schedules, remote work options, and opportunities for certification, making it suitable for those interested in healthcare and documentation skills.

How to get into CDI with no experience?

Entering clinical documentation improvement (CDI) roles with no experience typically involves gaining foundational knowledge through online courses or certifications such as Certified Clinical Documentation Specialist (CCDS). Developing strong medical terminology, coding, and documentation skills, along with familiarity with electronic health records (EHR) systems, can improve employability; some employers may offer entry-level positions or training programs for newcomers.
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 June 2026, with employment types broken down into 4% As Needed, 72% Full Time, 19% Part Time, 1% Temporary, 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 Specialist

Clinical Documentation Specialist

Northwell Health

Lake Success, NY • On-site

$37 - $49.75/hr

Full-time

Posted 2 days ago

Northwell Health rating

7.8

Company rating: 7.8 out of 10

Based on 549 frontline employees who took The Breakroom Quiz

131st of 872 rated healthcare providers

Job description

Job Description

Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided. Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers. Generates queries and have follow up discussions with physicians for clarification of ambiguous or conflicting documentation.

Job Responsibility

1.Facilitates clarification of clinical documentation ensuring accuracy and integrity in the medical record.
2.Facilitates appropriate clinical documentation to support diagnosis coding and ensure the appropriate level of service is recorded.
3.Works with physicians on assigned patient care units to clarify clinical documentation in the patient's medical record through a concurrent review process throughout the patient's inpatient stay.  
4.Requests clarification of clinical documentation from the physician(s) on a concurrent basis as needed to ensure documentation is complete and accurate prior to discharge.
5.Ensures the level of service rendered to patients, and the patient's severity of illness is accurately documented and recorded.
6.Follows up on CDI queries as needed to ensure appropriate documentation is recorded in the medical record. 
7.Interacts with physicians as needed to discuss and advise on clinical documentation requirements and provides timely and accurate responses to clinical documentation and coding questions. 
8.Demonstrates knowledge of ICD-10 CM and ICD-10 PCS coding, MS-DRG and APR NY and APR National grouper logic, documentation opportunities, clinical documentation requirements, and compliance to regulatory and facility policies and procedures. 
9.Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
10.Reconciles reviewed cases to update any changes in status, procedures/treatments, and confer with providers to finalize diagnoses. 
11.Educates medical staff on clinical documentation opportunities that impacts the accuracy of the medical record. 
12.Inputs outcome data in the CDI software to be able to track response to queries. Responsible for file maintenance including entry into database for tracking and trending audit results.  Communicate findings of potential or missed diagnoses and the revenue impact that were discovered during the chart audit.
13.Regularly exercises independent judgment on matters of significance within defined procedures todetermine appropriateactions/approaches
14.Understands department,division, corporate strategy and operating objectives, including impacts
15.Normally receives general instructions on routinework, detailed instructions on new projects or assignments
16.Majority of contact is within own function, area, or department and may be customer service oriented
17.Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here but considered related are not essential functions.

Job Qualification

Graduate from an accredited School of Nursing required. Must obtain a
Bachelor of Science in Nursing degree within 5 years of employment date.
Current License to practice as a Registered Professional Nurse in New York
State required, plus specialized certifications as needed. (CCEDS and CCS)
1-3 years of relevant experience, required.


*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

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