What Do Clinical Documentation Specialists Do?
Wondering what the job is really like for clinical documentation specialists?
You've come to the right place.
Keep reading to find detailed information about what clinical documentation specialists do, including the type of work they are tasked with on a daily basis, industries in which they work, and the specific skills needed for a successful career.
Clinical Documentation Specialists Overview & Description
Let's get started with the basics about clinical documentation specialists by taking a look at a simple description and popular job titles.
Clinical Documentation Specialists compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry’s numerical coding system. Includes medical coders.
Popular Job Titles For Clinical Documentation Specialists
Sample of Reported Job Titles
- Medical Billing Specialists
- Medical Scribes
- Medical Billers
- Medical Records Clerks
- Medical Records Specialists
- Health Information Specialists
- Inpatient Coders
- Medical Coders
- Medical Records Coordinators
- Medical Records Technicians
- Clinical Documentation Specialists
- Coding Specialists
Read on for insight into the industries where the highest concentration of jobs for clinical documentation specialists can be found.
Best Industries for Clinical Documentation Specialists
Clinical Documentation Specialists Jobs By Industry
- General Medical and Surgical Hospitals: 20.1%
- Offices of Physicians: 19%
- Management of Companies and Enterprises: 8.9%
- Nursing Care Facilities (Skilled Nursing Facilities): 4.8%
- Accounting, Tax Preparation, Bookkeeping, and Payroll Services: 4.3%
- Office Administrative Services: 4.2%
- Other: 38.7%
When it comes to jobs in the United States, the largest single category of clinical documentation specialists can be found working in the General Medical and Surgical Hospitals sector. In 2022, about 20.1% of all jobs for clinical documentation specialists were found there.
Other top industries by percentage include Offices of Physicians (19%), Management of Companies and Enterprises (8.9%), Nursing Care Facilities (Skilled Nursing Facilities) (4.8%), Accounting, Tax Preparation, Bookkeeping, and Payroll Services (4.3%) and Office Administrative Services (4.2%).
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What Do Clinical Documentation Specialists Do on a Daily Basis?
So you have a high-level understanding of what clinical documentation specialists do and the types of industries in which they work - but what do they really do each day?
A great way to understand the type of work clinical documentation specialists do is to examine actual job postings and focus on the specific skills that employers are seeking. That will help paint a clearer picture of the tasks that clinical documentation specialists tackle each day.
Continue reading for a breakdown of common skills - interpersonal qualities and attributes - that can help you thrive in the workplace.
In-Demand Skills for Today's Clinical Documentation Specialists
Top 5 Common Skills for Clinical Documentation Specialists
| Skills | Postings | % of Total Postings |
|---|---|---|
| Communications | 76,591 | 38% |
| Management | 47,703 | 24% |
| Customer Service | 46,415 | 23% |
| Detail Oriented | 34,101 | 17% |
| Operations | 30,866 | 15% |
For common skills, communications was the most desired skill found in job postings for clinical documentation specialists, followed by management, customer service, detail oriented, operations and writing.
| Skill | Postings | % of Total Postings |
|---|---|---|
| Communications | 76,591 | 38% |
| Management | 47,703 | 24% |
| Customer Service | 46,415 | 23% |
| Detail Oriented | 34,101 | 17% |
| Operations | 30,866 | 15% |
| Writing | 30,511 | 15% |
| Problem Solving | 29,850 | 15% |
| Leadership | 29,281 | 14% |
| Microsoft Excel | 28,527 | 14% |
| Research | 28,478 | 14% |
| Microsoft Office | 23,574 | 12% |
| Computer Literacy | 21,218 | 10% |
| Multitasking | 20,781 | 10% |
| Organizational Skills | 19,219 | 9% |
| Clerical Works | 18,556 | 9% |
| Collections | 18,464 | 9% |
| Interpersonal Communications | 17,922 | 9% |
| Verbal Communication Skills | 17,040 | 8% |
| Coordinating | 16,545 | 8% |
| English Language | 16,127 | 8% |
Most In-Demand Jobs for Clinical Documentation Specialists
Top 5 Posted Job Titles
| Job Title | Postings | % of Total Postings |
|---|---|---|
| Medical Billing Specialists | 26,121 | 11.7% |
| Medical Scribes | 38,347 | 17.1% |
| Medical Billers | 27,622 | 12.3% |
| Medical Records Clerks | 26,290 | 11.8% |
| Medical Records Specialists | 13,105 | 5.9% |
According to job postings that were published between September 2021 and August 2022, the top job sought by employers was medical billing specialists, with 8,898 unique job postings. Medical scribes were second, with 6,907 postings, followed by medical billers, medical records clerks and medical records specialists.
Expand the section below to see unique job postings for all occupations related to clinical documentation specialists.
| Job Title | Postings | % of Total Postings |
|---|---|---|
| Medical Billing Specialists | 26,121 | 11.7% |
| Medical Scribes | 38,347 | 17.1% |
| Medical Billers | 27,622 | 12.3% |
| Medical Records Clerks | 26,290 | 11.8% |
| Medical Records Specialists | 13,105 | 5.9% |
| Health Information Specialists | 9,345 | 4.2% |
| Inpatient Coders | 7,388 | 3.3% |
| Medical Coders | 8,000 | 3.6% |
| Medical Records Coordinators | 8,523 | 3.8% |
| Medical Records Technicians | 6,354 | 2.8% |
| Clinical Documentation Specialists | 7,001 | 3.1% |
| Coding Specialists | 5,151 | 2.3% |
| Healthcare Data Analysts | 4,908 | 2.2% |
| Coders | 5,165 | 2.3% |
| Patient Account Representatives | 7,881 | 3.5% |
| Medical Billers/Coders | 5,000 | 2.2% |
| Outpatient Coders | 4,033 | 1.8% |
| Health Information Management Technicians | 4,621 | 2.1% |
| Clinical Informatics Specialists | 4,151 | 1.9% |
| Medical Surgical Travel Registered Nurses | 4,720 | 2.1% |
Additional Links
Ready to dig deeper into career information for clinical documentation specialists? Visit our other pages focused on salary and education for clinical documentation specialists.
How much do clinical documentation specialists make?
Clinical Documentation Specialists: How do you become one?
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