Clinical Documentation Specialist Job Description and Salary

A career that offers a good balance of challenge and reward, the clinical documentation specialist must blend clinical and technical knowledge.

The accuracy of health records plays a key role in providing the best medical service, streamlining the practices of billing of agencies such as Medicaid, and maintaining the proper paperwork for insurance.

The documentation all healthcare operations must maintain in modern healthcare is vast, and the clinical documentation specialists plays a critical role in maintaining the required documents and the systems that manage them.

What is a Clinical Documentation Specialist?

A clinical documentation specialist (CDS) reviews a patient’s medical records to ensure documentation is accurate as well as up-to-date with the latest information on a patient’s illness. They also record the details of every step-in clinical treatment.

Bringing a blend of clinical and technical knowledge to the job, a clinical documentation specialist (CDS) validates diagnosis codes in medical records, finds missing diagnosis, and may follow up with doctors and nurses to fill in any gaps in the healthcare record.

It’s a critical job given the extent of documentation all healthcare operations must maintain in modern healthcare. The accuracy of health records plays a key role in providing the best medical service, streamlining the practices of billing of agencies such as Medicaid, and maintaining the proper paperwork for insurance.

A CDS must also make sure that a healthcare operation complies with HIPPA and other government regulations in terms of managing patient records.

What is the Role of a Clinical Documentation Specialist?

A CDS must have familiarity with the codes involved with medical records, each of which is used to indicate some aspect of the patient’s medical information, condition and the treatment received. The job also requires the ability to work with a team. A CDS must have the clinical knowledge to talk with doctors, nurses and other healthcare providers about the treatment a patient has received, especially if there are gaps in the healthcare record.

While daily duties can vary depending on where a CDS is working, a typical day may include the following.

  • Evaluating records for patients to ensure accuracy and completeness
  • Ensuring that there is proper documentation where needed – for example, for Medicaid or insurance billing
  • Tracking outcomes for individual patients to measure the quality of services provided
  • Following up with doctors and nurses where needed to complete an individual patient’s records
  • Contacting insurance companies on issues related to a patient’s record

A CDS can work primarily with records or, in a management position, oversee a team of CDS workers.

Clinical Documentation Specialist Salary and Career Growth

The attention to detail a CDS position requires, as well as the blend of clinical and technical knowledge, makes the CDS position a difficult position for healthcare operations to fill.

That’s one reason for the high demand associated with this title. The U.S. Bureau of Labor Statistics (BLS) projects that the number of medical records and health information technicians will grow by 8% from 2019 to 2029.1 In Florida, which is the third highest employer of people in this field, the number is expected to grow 18% from 2018 to 2028, according to Projections Central, a BLS-powered site that breaks down job numbers by state.2

The median annual wage for medical records and health information technicians was $42,630 as of May 2019, according to BLS figures, with those with a graduate degree earning about $249 more per week than those with an undergraduate degree, based on earnings by educational attainment.

Clinical Documentation Specialist Education Requirements

While you do not need a graduate degree or certification to enter the field, a degree from an accredited institution is a valuable asset if you intend to pursue higher-level jobs in clinical documentation.

Of course, clinical documentation is not something people typically major in. Rather, those who wish to pursue a CDS position can earn a graduate degree or graduate certificate in health informatics, a major that covers the use of technology in healthcare.

In many cases, those drawn to the profession are healthcare professionals, such as nurses, who want to work in health informatics. The clinical expertise they bring to the profession makes them exceptional candidates for a career as a CDS.

In addition to the soft skills that can help people land leadership positions, graduate-level courses teach the fundamentals of health informatics, as well as issues such as managerial communications and the legal aspects of health information management.

Learn more about the online Health Informatics and Healthcare Analytics programs from USF Health.

*National long-term projections may not reflect local and/or short-term economic or job conditions, and do not guarantee actual job growth. Information provided is not intended to represent a complete list of hiring companies or job titles, and program options do not guarantee career or salary outcomes. Students should conduct independent research for specific employment information.

1Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Medical Records and Health Information Technicians. https://www.bls.gov/ooh/healthcare/medical-records-and-health-information-technicians.htm#tab-1 (visited December 14, 2020).

2Projections Central – State Occupational Projections. Long Term Occupational Projections (2018-2028). Florida Medical Records and Health Information Technicians. https://www.projectionscentral.com/Projections/LongTerm (visited December 14, 2020).

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