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 Billers
- Medical Records Clerks
- Medical Records Specialists
- Inpatient Coders
- Medical Coders
- Coders
- Clinical Documentation Specialists
- Medical Records Technicians
- Medical Records Coordinators
- Medical Billers/Coders
- 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: 20.3%
- Offices of Physicians: 19.2%
- Management of Companies and Enterprises: 9.2%
- Nursing Care Facilities (Skilled Nursing Facilities): 5.2%
- Education and Hospitals (Local Government): 4.4%
- Outpatient Care Centers: 4.2%
- Other: 37.5%
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 2023, about 20.3% of all jobs for clinical documentation specialists were found there.
Other top industries by percentage include Offices of Physicians (19.2%), Management of Companies and Enterprises (9.2%), Nursing Care Facilities (Skilled Nursing Facilities) (5.2%), Education and Hospitals (Local Government) (4.4%) and Outpatient Care Centers (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 specialized skills found in job postings for clinical documentation specialists, as well as common skills - interpersonal qualities and attributes - that can help you thrive in the workplace.
In-Demand Skills for Today's Clinical Documentation Specialists
Based on 69,484 job postings
Top 5 Specialized Skills for Clinical Documentation Specialists
| Skills | Postings | % of Total Postings |
|---|---|---|
| Medical Records | 34,298 | 49% |
| Billing | 30,990 | 45% |
| ICD Coding (ICD-9/ICD-10) | 22,455 | 32% |
| Medical Billing | 18,748 | 27% |
| CPT Coding | 18,636 | 27% |
Top 5 Common Skills for Clinical Documentation Specialists
| Skills | Postings | % of Total Postings |
|---|---|---|
| Communication | 22,349 | 32% |
| Management | 15,604 | 22% |
| Detail Oriented | 14,905 | 21% |
| Customer Service | 14,326 | 21% |
| Research | 11,319 | 16% |
Based on 69,484 job postings related to clinical documentation specialists, medical records was the top specialized skill sought by employers, with 49% of all postings looking for that skillset. Skills for billing, icd coding (icd-9/icd-10), medical billing, cpt coding and medical terminology were also highly sought.
As for common skills, communication was the most desired skill found in job postings for clinical documentation specialists, followed by management, detail oriented, customer service, research and collections.
| Skill | Postings | % of Total Postings |
|---|---|---|
| Medical Records | 34,298 | 49% |
| Billing | 30,990 | 45% |
| ICD Coding (ICD-9/ICD-10) | 22,455 | 32% |
| Medical Billing | 18,748 | 27% |
| CPT Coding | 18,636 | 27% |
| Medical Terminology | 18,245 | 26% |
| Electronic Medical Record | 14,447 | 21% |
| Medical Coding | 14,109 | 20% |
| Auditing | 11,944 | 17% |
| Medicare | 10,992 | 16% |
| Health Information Management | 9,445 | 14% |
| Anatomy | 8,684 | 12% |
| Healthcare Common Procedure Coding Systems | 8,307 | 12% |
| Medicaid | 8,191 | 12% |
| Physiology | 8,167 | 12% |
| Data Entry | 8,034 | 12% |
| Revenue Cycle Management | 7,814 | 11% |
| Accounts Receivable | 7,399 | 11% |
| Clinical Documentation | 7,264 | 10% |
| Procedure Codes | 5,670 | 8% |
| Skill | Postings | % of Total Postings |
|---|---|---|
| Communication | 22,349 | 32% |
| Management | 15,604 | 22% |
| Detail Oriented | 14,905 | 21% |
| Customer Service | 14,326 | 21% |
| Research | 11,319 | 16% |
| Collections | 10,044 | 14% |
| Microsoft Excel | 9,445 | 14% |
| Writing | 8,246 | 12% |
| Microsoft Office | 8,023 | 12% |
| Operations | 8,021 | 12% |
| Computer Literacy | 7,470 | 11% |
| Organizational Skills | 7,348 | 11% |
| Multitasking | 7,327 | 11% |
| Problem Solving | 6,931 | 10% |
| Interpersonal Communications | 6,057 | 9% |
| Clerical Works | 6,008 | 9% |
| Filing | 6,002 | 9% |
| Leadership | 6,001 | 9% |
| Verbal Communication Skills | 5,317 | 8% |
| Ethical Standards And Conduct | 5,026 | 7% |
Most In-Demand Jobs for Clinical Documentation Specialists
Top 5 Posted Job Titles
| Job Title | Postings | % of Total Postings |
|---|---|---|
| Medical Billing Specialists | 16,827 | 17.6% |
| Medical Billers | 15,649 | 16.4% |
| Medical Records Clerks | 8,534 | 8.9% |
| Medical Records Specialists | 8,110 | 8.5% |
| Inpatient Coders | 4,967 | 5.2% |
According to job postings that were published between September 2022 and August 2023, the top job sought by employers was medical billing specialists, with 5,832 unique job postings. Medical billers were second, with 3,737 postings, followed by medical records clerks, medical records specialists and inpatient coders.
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 | 16,827 | 17.6% |
| Medical Billers | 15,649 | 16.4% |
| Medical Records Clerks | 8,534 | 8.9% |
| Medical Records Specialists | 8,110 | 8.5% |
| Inpatient Coders | 4,967 | 5.2% |
| Medical Coders | 5,245 | 5.5% |
| Coders | 3,993 | 4.2% |
| Clinical Documentation Specialists | 4,695 | 4.9% |
| Medical Records Technicians | 2,669 | 2.8% |
| Medical Records Coordinators | 2,547 | 2.7% |
| Medical Billers/Coders | 4,068 | 4.3% |
| Coding Specialists | 2,932 | 3.1% |
| Outpatient Coders | 2,728 | 2.9% |
| Pro Fee Coders | 1,580 | 1.7% |
| Medical Staff Coordinators | 1,722 | 1.8% |
| ROI Medical Records Specialists | 2,107 | 2.2% |
| Certified Coders | 1,854 | 1.9% |
| Medical Billers/Collectors | 1,762 | 1.8% |
| Medical Billing Clerks | 1,510 | 1.6% |
| Medical Billing and Coding Specialists | 1,856 | 1.9% |
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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