ZipRecruiter

Log In

1

Clinical Documentation Jobs (NOW HIRING)

Northwell

Clinical Documentation Specialist

Lake Success, NY · On-site

$37 - $49.75/hr

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 ...

Quorum Health

Clinical Documentation Specialist

Brentwood, TN · On-site

$33 - $44.25/hr

Clinical Documentation Specialist Position Details: Full Time - Remote Reports to the National Director, Clinical Documentation Integrity Must reside in one of the States listed below to be eligible ...

next page

Showing results 1-20

All JobsClinical Documentation Jobs

Clinical Documentation information

See salary details

$18

$39

$59

How much do clinical documentation jobs pay per hour?

As of Jul 14, 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 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.
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 July 2026, with employment types broken down into 3% As Needed, 72% Full Time, 18% Part Time, and 7% Contract. Highlights an 95% Physical, 1% 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

Community First Medical Center

Chicago, IL • On-site

$70K - $85K/yr

Full-time, Part-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 25 days ago

Community First Medical Center rating

3.9

Company rating: 3.9 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

1,006th of 1,020 rated hospitals

Job description

Description:

Opportunity for Full Time Days Monday-Friday

Will be on site

Clinical Documentation Specialist will ensure the overall quality and completeness of clinical documentation in patient medical records through extensive concurrent review, and concurrent interaction with physicians, care team members, case management, health information management and others as applicable. Monitors the documentation process and facilitates modifications to documentation to ensure clinical severity and intensity of service is documented to support the level of service and treatment rendered, to ensure accurate description of reasons for admission, patient severity, risk of mortality and conditions present on admission.


ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Review inpatient medical records using EMR for identified payer populations on admission.

2. Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.

3. Works collaboratively with the coding staff to ensure documentation of principal diagnosis.

4. Facilitates modifications and improvements to clinical documentation.

5. Track successes and opportunities of the program by analyzing data obtained from tracking reports.

6. Collaborates with Case Management, Quality Improvement and other individuals.

7. Participates in committees as assigned and with planning and delivering educational initiatives.

8. Coordinates and facilitates team meetings in collaboration with the coding staff and others, as required.

9. Other duties as assigned.


Community First Medical Center offers benefits to all its full-time and part-time employees:

  • United Healthcare Medical PPO/HMO/HSA Plans, premiums as low as $50.00/full time, $85.00/Part Time
  • Met Life Dental and Vision
  • Paid Time Off (PTO) with annual accruals up to 168 hrs./year
  • Six paid holidays
  • Company Paid Life insurance and Short-term Disability
  • 401(k) after 90 days
  • Continuing Education reimbursement and 2 days paid off separate from PTO
  • Free Parking Garage
  • Internal Growth Opportunities
Requirements:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

  • Must effective writing skills, critical-thinking and problem- solving skills, be self-motivated and manage deadlines.
  • Must have strong interpersonal skills to effectively interact with a variety of staff.
  • Graduate of an accredited school of nursing with current Illinois license, required.
  • Bachelor’s Degree in Nursing, Medicine or Associate’s degree in Health Information
  • Management with RHIT credentials required, Bachelor’s Degree in Health Information Management preferred.
  • R.N. must have a minimum of 5 years of recent acute care experience.
  • HIM professionals must have a minimum of 3 years of recent in-patient, acute care coding experience.
  • RN, RHIT or RHIA with 2 yrs. experience in a clinical documentation specialist role or Utilization Review.
  • Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT), preferred
  • Knowledge of MS-DRG and reimbursement principles
  • Knowledge of Microsoft Word, Outlook, electronic medical record
  • Knowledge of EPIC patient information systems preferred.
  • Knowledge of a 3rd party clinical documentation management application preferred

Community First Medical Center is an affirmative action/equal opportunity employer who is committed to cultivating diversity, equity and inclusion within all aspects of our organizations. We stand against and prohibit discrimination in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

What Community First Medical Center employees say

Pay

Hours and flexibility

Workplace

Get the full story on Breakroom