ZipRecruiter

Log In

1

Clinical Documentation Jobs (NOW HIRING)

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 ...

UHS

CLINICAL DOCUMENTATION COORD

West Palm Beach, FL · On-site

$32.50 - $43.75/hr

Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Supports the accuracy and completeness ...

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

UNC Health Blue Ridge

Morganton, NC • On-site

$27.75 - $37.50/hr

Full-time

Medical

Re-posted 13 days ago

Job description

THE ORGANIZATION
At UNC Health Blue Ridge, we live our mission by enhancing the lives of every patient and resident we serve. We believe our people are our greatest asset and strive to provide an environment where they can thrive.
You'll love working with us because:
  • We are a teaching hospital
  • We work together to ensure our patients receive outstanding, holistic care
  • Your expertise and ideas are valued
  • Your health and well-being matter
  • And much more

"I love working at UNC Health Blue Ridge because I know I am seen and valued. I know this is where I belong and that allows me to give my very best to my patients and their families ."
THE POSITION
Join our team as a Clinical Documentation Specialist, where you will play a crucial role in ensuring the accuracy and integrity of our clinical documentation processes. Your expertise will contribute to enhancing patient care, optimizing compliance, and improving operational efficiency. Be a part of an innovative healthcare environment that values precision, collaboration, and continuous improvement. Minimum 3 years acute-care hospital experience as Documentation Specialist or Inpatient Coder. AHIMA credential of RHIT or RHIA or CCS or CDIP or ACDIS CCDS required within 24 months of hire; Licensed RN preferred but must have coding experience.
  • Generous tuition assistance/reimbursement program
  • Competitive benefits package

THE LOCATION
You'll love living here.
  • Abundance of recreational activities in our backyard
  • Excellent public schools
  • High-quality health care
  • Lower cost of living
  • Moderate climate
  • Proximity to scenic attractions
  • Higher education facilities located nearby
  • Short drive to key cities such as Asheville, Charlotte, and Winston-Salem

Apply