What is a Clinical Documentation Specialist job?
A Clinical Documentation Specialist job is one of the most important roles in healthcare. It is a position that requires a person to review and analyze medical records to ensure that they are accurate, complete, and meet regulatory requirements. Clinical Documentation Specialists work to ensure that the medical records are clear, concise, and complete, which allows healthcare providers to make informed decisions about patient care.
What usually do in this position?
A Clinical Documentation Specialist typically reviews medical records to ensure that they are accurate and complete. They also work with healthcare providers to clarify any ambiguous or incomplete information in the records. In addition, they may provide training to healthcare providers on effective documentation practices.
Top 5 Skills for Position
- Strong analytical skills
- Excellent communication skills
- Attention to detail
- Knowledge of medical terminology
- Ability to work independently and as part of a team
How to become this type of specialist?
To become a Clinical Documentation Specialist, you typically need a bachelor's degree in a healthcare-related field, such as nursing or healthcare administration. Some employers may require additional certification, such as the Certified Clinical Documentation Specialist (CCDS) credential from the Association of Clinical Documentation Integrity Specialists (ACDIS).
Average Salary
According to Glassdoor, the average salary for a Clinical Documentation Specialist in the United States is $72,000 per year. However, salaries can vary depending on factors such as location, experience, and level of education.
Roles and Types
Clinical Documentation Specialists can work in a variety of healthcare settings, including hospitals, clinics, and long-term care facilities. Some may specialize in a particular area of healthcare, such as pediatrics or oncology. Other roles within the field include Clinical Documentation Improvement Specialist, Clinical Documentation Manager, and Clinical Documentation Educator.
Locations with the most popular jobs in USA
According to the Bureau of Labor Statistics, the states with the highest employment levels for Medical Records and Health Information Technicians (which includes Clinical Documentation Specialists) are California, Texas, Florida, New York, and Pennsylvania.
What are the typical tools?
Clinical Documentation Specialists typically use a variety of tools, including electronic health record (EHR) systems, coding software, and medical dictionaries and references. They may also use Microsoft Office programs such as Word and Excel to manage and analyze data.
In Conclusion
A Clinical Documentation Specialist job is a critical role in healthcare that requires a combination of analytical and communication skills. With the right education and training, this career can be both financially rewarding and personally satisfying. If you are interested in a career in healthcare that allows you to make a difference in patient care, becoming a Clinical Documentation Specialist may be the right path for you.