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Clinical Documentation Jobs (NOW HIRING)

Ascension

Clinical Documentation Specialist

Shorewood, WI · Remote

$79.51K - $110.83K/yr

Clinical Integrity Documentation Schedule: Days | Full Time Salary Range: $79,511.52-$110,834.59 How you'll make an impact in this role Facilitate improvement in overall quality, completeness and ...

NS Pharma Inc

Manager, Clinical Documentation

Paramus, NJ · On-site

$110K - $140K/yr

This position is responsible for supporting and maintaining the Quality Management System (QMS) for clinical research activities conducted in the U.S., including SOP lifecycle management, document ...

FMOLHS

Manager Clinical Documentation

Baton Rouge, LA

$33.25 - $45/hr

Facilitates compliant modifications to clinical documentation to accurately reflect patient severity of illness, risk of mortality through extensive interaction with physicians, Case Management ...

Coxhealth

Clinical Documentation Specialist

Springfield, MO

$31.50 - $42.50/hr

This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines. Understand and utilization of ICD-10-CM and PCS ...

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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 Specialist

Clinical Documentation Specialist

University of California San Francisco

San Francisco, CA

$41 - $55/hr

Other

Posted 5 days ago

Job description

Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient's severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any coexisting co-morbidities are a complete reflection of the patient's clinical status and care. Involves education and training to physicians and clinical staff (nurses and therapists) as part of the onboarding and as rules and regulations change in the IRF level of care. The final salary and offer components are subject to additional approvals based on UC policy.

Required Qualifications :

  • Min 2 years Clinical experience post-grad in a hospital setting. 
  • Working knowledge and experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, case management, discharge, and other practices that are part of effective clinical care systems.
  • Detail oriented, with demonstrated ability to effectively manage time, see tasks through to completion, organize competing priorities, and effectively address complex, urgent issues as they arise.
  • Demonstrated critical-thinking and problem-solving skills to manage multiple levels of information and responsibilities, and quickly assess problems to develop multiple potential solutions.
  • Demonstrated interpersonal and educational skills, with the ability to collaborate effectively with clinical-care professionals, and to serve as an educational resource on coding, reimbursement, and other clinical documentation issues.  
  • Demonstrated ability to interpret and effectively explain clinical and technical information both verbally and in writing, and to contribute to presentations, reports, and analyses as assigned.
  • Demonstrated ability to work with senior staff and managers and to provide recommendations on issues of functionality, clinical quality, and efficiency.
  • Demonstrated computer proficiency in relevant multiple technology applications.
  • Has flexibility to work across the system
  • Bachelor's degree in PT, OT or Master in SLP or related area, and / or equivalent combination of experience / training
    California License on respective fields (PT, OT, SLP or RN)

Preferred Qualifications :
 

  • Working knowledge of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes.
  • Working knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement.
  • PT

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