Clinical Documentation Specialist Careers: Job Description & Salary Info

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Get the truth about a clinical documentation specialist's salary, education requirements and career prospects. Read the job description and see the pros and cons of becoming a clinical documentation specialist.
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A Clinical Documentation Specialist Career: Pros and Cons

A clinical documentation specialist reviews medical records, checking for accuracy and completeness. Check out the pros and cons of a career as a clinical documentation specialist to see if it's right for you.

Pros of Becoming a Clinical Documentation Specialist
High rate of employment growth (22% between 2012-2022)*
Entry-level positions may be available with an associate's degree or less*
High earnings potential with several years of experience**
Ensuring accuracy of records improves patient care**

Cons of Becoming a Clinical Documentation Specialist
Usually requires several years of job experience**
Professional certifications may be required**
Continuing education is often needed to stay updated on medical records technology*
Most of the job duties take place in front of a computer*

Sources: *U.S. Bureau of Labor Statistics, **CareerBuilder.com

Career Information

Job Description

As a clinical documentation specialist, you'd work for hospitals, medical service providers and healthcare systems monitoring the quality of patient records. You'd make sure clinical charts and records contain the right information about treatment, care, diagnoses and severity for proper coding, billing and follow-up. Instead of working directly with patients, you would communicate with doctors, nurses, healthcare professionals and the medical records technicians who compile information to clarify issues, fix errors or add missing information. You may also help educate medical staff and records technicians to improve documentation practices and ensure that regulations and policies are being followed.

Salary Info and Career Outlook

While the statistics for this exact occupation are based on a comparatively small sample of professionals who use this title, Payscale.com figures from July 2015 showed that workers in the 10th-90th percentile earned between $47,000 and $88,000 per year. The U.S. Bureau of Labor Statistics (BLS) provided wage information for the broader category of medical records and health information technicians, with median annual earnings of around $36,000; these figures, however, include entry-level medical records employees, while job postings for clinical documentation specialists generally indicate that these professionals have more education and experience, according to the BLS.

The BLS estimated employment growth for the broad category of medical records and health information technicians at 22% between 2012 and 2022; this group includes clinical documentation specialists, for whom more precise job outlook figures are not available. Employment growth in the healthcare field, which is faster than the average for all occupations, will continue to rise as the population ages and requires more medical services.

What Do Employers Expect?

Education Requirements

Entry-level medical records technicians, medical coders and other health information technicians can often start their careers with education ranging from a high school diploma to a postsecondary certificate or an associate's degree. In these programs, you'd usually learn how to use computers and access medical records information systems; you'd also take classes in medical coding, billing and reimbursement, human anatomy, medical terminology and pharmacology. Clinical documentation specialists, however, usually have additional education, with many employers preferring a bachelor's degree, as well as several years of experience as a health information technician, medical coder or nurse in a clinical setting.

Certifications and Licenses

In addition to job experience, many employers will prefer or expect you to have gained one or more industry certifications, since these credentials reflect established levels of education, experience, skills and knowledge. The American Health Information Management Association (AHIMA) grants three certifications frequently requested by employers, which include the Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) and Certified Coding Specialist (CCS) designations; each certification has specific eligibility and continuing education requirements (www.ahima.org). If you come to the clinical documentation position with nursing experience, employers typically want you to be a registered nurse (RN) and hold a valid state nursing license.

Career Skills

Because you'd interact extensively with doctors, nurses, medical records staff and other healthcare professionals as a clinical documentation specialist, you would need to have excellent communication skills and be able to work well with a variety of people. Maintaining the accuracy of medical records also requires exceptional attention to detail and critical thinking, especially to recognize when additional information is needed. As an experienced coder or clinical care provider, you would need to have a thorough understanding of medical documentation, coding systems, insurance programs and information management systems, as well as be well-versed in a variety of computer software, applications and data management programs.

Job Postings from Real Employers

Employer expectations varied widely regarding education requirements, but they often require between three and five years of previous work experience in medical coding, acute care or another clinical setting. Below is a sample of available job postings listed on CareerBuilder.com in May 2012:

  • A North Carolina medical center wanted a clinical documentation specialist to review medical records. Stated goals included improving the specificity of documentation and monitoring regulatory compliance.
  • A healthcare network in Philadelphia advertised for a clinical documentation specialist to educate staff on diagnosis and documentation requirements and serve as a communication facilitator to improve the quality, accuracy and completeness of patient records.
  • A university-affiliated health system in Chicago sought a registered nurse to assist with coding accuracy, review insurance documentation for admitted patients and communicate with medical staff to promote increased specificity.

How to Get an Edge in the Field

Obtain Professional Certification

In addition to the credentials mentioned earlier, an additional certification is available that specifically represents the competencies and knowledge base needed to work as a clinical documentation specialist. The Association of Clinical Documentation Improvement Specialists (ACDIS) offers the Certified Clinical Documentation Specialist (CCDS) program for individuals with at least one year of professional experience in this role. To qualify for the credentialing exam, you'll need a combination of education, experience and training; the certification lasts two years and requires completing continuing education hours.

Update Your Skills

Changes to state and federal regulations, coding methods, insurance regulations, medical technology and computer data management systems can make continuing education essential if you want to stay up-to-date in this multidisciplinary field. Coursework, seminars or professional development activities in medical coding practices, health information management, health policy and regulation can help you understand better ways to manage medical records and assist personnel in more accurate coding.

Other Careers to Consider

If you would like to work in a hospital, medical facility or other healthcare organization but prefer a job with supervisory and administrative duties, you could consider becoming a medical and health services manager. In this role, you might manage a nursing home, oversee a clinical practice area or direct the operations of a medical practice. O*Net OnLine figures from 2011 showed that 52% of people in this occupation held a bachelor's degree, while 41% held a master's degree. Although considerable knowledge and experience may be required for these positions, the financial compensation is excellent: the average salary was around $96,000 as of 2011. Additionally, the BLS predicted healthy job growth of 22% through 2020.

If you want to work with both employees and executives outside of the healthcare industry, a career as a human resources manager may appeal to you. In this career, you'll use interpersonal, communication and conflict resolution skills to help employees succeed, create workplace policies, oversee staffing and assist management with employee relations issues. A bachelor's degree is often required, with a major or coursework in human resources management, business administration or related disciplines. In 2011, human resources managers had average annual earnings of around $109,000. Job growth, however, is expected to be as fast as the average for all occupations between 2010 and 2020, at a rate of 13%.

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Featured Schools

George Mason University

  • Master of Health Administration in Health Systems Management
  • Master of Science in Health Informatics

What is your highest level of education?

The George Washington University

  • MSHS in Clinical Research Administration
  • MSHS in Regulatory Affairs
  • Graduate Certificate in Clinical Research Administration
  • Graduate Certificate in Regulatory Affairs

What is your highest level of education?

Johns Hopkins University

  • Master of Science in Regulatory Science

What is your highest level of education?

American University

  • Master of Science in Healthcare Management

What is your highest level of education?

Herzing University

  • MBA Dual Concentration: Healthcare Management and Public Safety Leadership
  • MBA Dual Concentration: Accounting and Public Safety Leadership
  • MBA Dual Concentration: Business Management and Public Safety Leadership

What is your highest level of education?

Virginia College

  • Diploma Program - Pharmacy Technician
  • Certification - Pharmacy Technician

What is your highest level of education completed?

Keiser University

  • Associate of Sciences - Medical Assistant

What is your highest level of education?

Colorado Technical University

  • Doctor of Management - Health Care Management and Leadership
  • MS - Healthcare Management
  • BS - Business Administration - Health Care Management

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