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Detail-oriented Clinical Documentation Specialist Job Description

The job description of a clinical documentation specialist requires a medical professional to work in an administrative capacity. Such specialists can work in hospitals, physician practices, clinics and other medical facilities.

Position Description

A clinical documentation specialist has the task of managing the creation of clinical files and maintaining the files as part of a patient’s medical record.

Essential Duties and Responsibilities of a Clinical Documentation Specialist

  • Collects information about patients’ diagnoses and enters it into computer databases.
  • Assesses all patient medical documents to ensure accuracy.
  • Tracks information on diseases.
  • Educates medical coders and billers on standard procedures that must be followed when composing medical documents.
  • Recommends strategies for improving record keeping processes.
  • Ensures all clinical documents are in compliance with federal laws in terms of composition and secure storage.
  • Analyzes medical information to assist healthcare staff in providing superior services for patients.
  • Applies knowledge of medical terminology and medical procedures to properly evaluate clinical documents.
  • Prepares written reports for public health officials who evaluate healthcare facilities.
  • Interprets clinical reports to identify health-related patterns and assists in addressing patient health problems.
  • Meets with clinical staff to explain reports.
  • Ensures that records are kept in proper order so that patients’ health information can be easily located.
  • Conducts research and performs administrative duties.
  • Trains information specialists on proper methods of documentation and maintenance of medical records.
  • Takes continuing education courses and stays up-to-date on changes in laws governing clinical documentation.

Required Knowledge, Skills and Abilities

  • Must be highly detail oriented.
  • Exceptional analytical and critical thinking skills.
  • Excellent written and verbal communication skills.
  • Must have superior organizational skills.
  • Strong leadership skills.
  • Must have excellent interpersonal skills.
  • Must have good time management skills.
  • Must have strong negotiation skills.
  • Must have excellent computer skills and knowledge of software for database maintenance and electronic health record storage.
  • Knowledge of clinical conditions and procedures, medical coding and basic documentation requirements.
  • Knowledge of accepted quality assurance procedures.
  • Knowledge of patient privacy laws.

Education and Experience

  • Associate’s degree in Health Information Technology orApplied Sciences and a Licensed Practical Nurse or LPN designation.
  • Bachelor’s degree in Health Information Technology and a Registered Nurse or RN designation.
  • Master’s degree in Health Informatics or Health Information Management.
  • Certified Clinical Documentation Specialist or CCDScredentials through the Association of Clinical Documentation Improvement Specialistsor ACDIS.
  • Certification as a Registered Health Information Technician, or RHIT, from the American Health Information Management Association or AHIMA, or fromthe American Academy of Professional Coders, otherwise known as the AAPC.

Work Environment

  • Must be able to work in a very fast-paced environment.
  • Time will be spent looking at a computer screen and keyboarding.
  • Must be able to view photographs of real surgical procedures.
  • Must be able to effectively deal with physicians who are defensive about their documentation practices.
  • Must be able to work normal business hours of 8:00a.m. to 5:00p.m. Monday through Friday and longer hours based on workload.


  • Salaries range from $35,000 to $85,000 depending on the level of education, years of experience and location and size of the facility of employment.

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