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Clinical Documentation Jobs (NOW HIRING)

Ascension

Clinical Documentation Specialist

Shorewood, WI · Remote

$79K - $110K/yr

Clinical Integrity Documentation Schedule: Days | Full Time Salary Range: $79,511.52-$110,834.59 What You Will Do Facilitate improvement in overall quality, completeness and accuracy of medical ...

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Clinical Documentation information

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$18

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$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 Speclst

Clinical Documentation Speclst

BronxCare Health System

Bronx, NY

$36.25 - $48.75/hr

Full-time

Posted 29 days ago

BronxCare Health System rating

7.0

Company rating: 7.0 out of 10

Based on 6 frontline employees who took The Breakroom Quiz

Job description

Overview

Provides concurrent and retrospective review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Key responsibility will be to review the chart for information not currently in the chart but that is indicated by clinical indicators in the record. Queries the medical staff when necessary by written and/or verbal communication to obtain accurate andcomplete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.

Responsibilities

Establish and maintain positive relationships with patients, visitors and other employees. Interacts professionally, courteously, and appropriately with patients, visitors, and other employees. Behave in a manner consistent with maintaining and furthering a positive public perception of BronxCare Health System and its employees.

Contribute to and participate in the Performance/Quality Improvement activities of the assigned department. Contribution and participation includes data collection, analysis, implementation of and compliance with corrective/improvement activities, membership on CQI teams, consistent adherence to established performance standards and: adherence to the specific rules and regulations of the BronxCare Health System's Safety & Security Policies; Risk Management: Incident and Occurrence Reporting; Infection Control Policies and Procedures; Patient and Customer Service.

Coordinates and maintains all elements of the Clinical Documentation Improvement Program in order to meet the goals and objectives of the organization and its stakeholders

Meet CDI program objectives, goals, and balance scorecard metrics.

Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.

Ensure effective communications with key stakeholders.

Analyzes data, creates reports to meet desired outcomes.

Identifies trends and opportunities for improvement in clinical documentation

Meets program quality and productivity guidelines and standards.

Collaborates with coding professionals to fully support the needs of clinical code assignment, communicates proficiently with coding professionals to resolve identified discrepancies.

Work effectively with CDI team members to accomplish departmental goals.

Demonstrates continued advancement in professional growth.

Qualifications

Bachelor's

MD; MBBS or any equivalent degree

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.

Knowledge of age-specific patient needs and the elements of disease processes and related procedures.

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

Employment Type: FULL_TIME
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About BronxCare Health System

Sourced by ZipRecruiter

BronxCare is the largest voluntary, not-for-profit health and teaching hospital system serving the South and Central Bronx, with 859 beds and more than 4,500 employees. Its two main hospital divisions, comprehensive psychiatric and chemical dependency programs, long-term care facility, and extensive outpatient network are delivering the highest quality and accessible services to the community. BronxCare is now among the largest providers of outpatient services in New York City, with close to one million visits annually. Its ER is one of the busiest in New York.

Industry

Health care and social assistance

Company size

1,001 - 5,000 Employees

Headquarters location

New York, NY, US

Year founded

1890

Social media

Twitter

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