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How to Become a Clinical Documentation Specialist: Certification & Salary

Jan 07, 2021

What is a Clinical Documentation Specialist?

Clinical documentation specialists manage clinical trial and service documents. They ensure accuracy and quality among medical coders, doctors, nurses, and other healthcare staff. They maintain charts, medical records, and reports and solve any issues involving documentation. These specialists are expected to handle discrepancies, complete reports, work collaboratively within teams, and analyze data so that meaningful change may be made.

Clinical documentation specialists, like other types of medical records and health information technicians, work full-time. Such specialists work primarily during regular business hours, with some exceptions possible. The majority work in hospitals, clinics, or laboratories where medical clinical trials take place. Specialists primarily work in cities where larger quantities of information must be recorded and analyzed in conjunction with higher population and demand.

Clinical documentation specialists have associate's or bachelor's degrees in nursing, health information management or health information technology, and 2-5 years of experience in the field. They're expected to have medical coding expertise and CDI certification, along with excellent communication, leadership, interpersonal, organizational, and multitasking skills.

Clinical Documentation Specialist Salary in the United States

According to Salary.com, the median documentation specialist salary was $82,428 in 2020. This salary ranges from state to state and typically falls within $75,924 to $88,984. CDI specialist salary is dependent on a number of factors including:

  • clinical documentation specialist education
  • certifications held
  • years of experience within the profession
  • other skills relevant to the workforce.

The hourly rate for a clinical documentation specialist ranges from $37 to $43 an hour.

Clinical Documentation Specialist Career Requirements

Now let's go over the steps required to become a clinical documentation specialist.

How to Become a Clinical Documentation Specialist

Step 1: Complete an undergraduate program

Because employers prefer to hire licensed nurses and registered health information professionals, students can pursue post-secondary clinical documentation specialist education in either nursing or health information. Many schools offer associate's and bachelor's degree programs designed for aspiring RNs and LPNs; in some cases, prospective nurses may earn certificates or diplomas instead. Common course topics include mental health, patient assessment, and professional ethics. Most programs include internships or field experiences.

Students who are more interested in health information can pursue an associate's degree in health information technology or a bachelor's degree in health information management. These programs may cover data analysis and informatics, anatomy, physiology, medical terminology, and coding procedures. internships are often part of the curriculum as well.

Be sure to gain medical coding expertise. Employers often look for documentation specialists with knowledge of different coding systems. Students should make sure their chosen educational path includes coding coursework. A CCDS certification or CDI certification will make candidates desirable to hiring teams.

Step 2: Get licensed or certified

RN or LPN nursing program graduates may qualify for licensure by taking an exam. Likewise, graduates of health information technology associate's programs can earn the American Health Information Management Association's (AHIMA) Registered Health Information Technician (RHIT) credential by passing a test. Earning a bachelor's degree in health information management can prepare students for credentialing as a Registered Health Information Administrator (RHIA).

Step 3: Gain work experience

Prospective clinical documentation specialists usually need 2-5 years of work experience in nursing or health information management. According to the BLS, RNs typically begin their careers as staff nurses in hospitals or community health settings. Common duties for nurses include obtaining medical histories, assessing patients, and running tests.

RHITs can gain experience working as medical coders or records technicians in hospitals, doctors' offices, clinics, or other healthcare settings. These professionals maintain the security of patients' records, code medical information, and organize databases. RHIAs work in a variety of healthcare settings as well; they're responsible for overseeing all patient records and keeping up with current health information regulations.

Step 4: Become a clinical documentation specialist

After gaining enough experience in nursing or health information, individuals may qualify for work as clinical documentation specialists. These professionals review records for coding accuracy, follow-up with physicians, and inform medical staff members of updated documentation methods.

Step 5: Earn CCDS certification

Clinical documentation specialists can earn voluntary documentation certification through the Association of Clinical Documentation Improvement Specialists. The Certified Clinical Documentation Specialist (CCDS) credential provides proof of competency in the field and may lead to career advancement. To qualify for the CCDS exam, applicants need 1-2 years of professional documentation experience combined with college-level coursework.

Step 6: Maintain your licensure or certification

In most cases, a license or certification must be renewed after a certain period of time. For example, RNs often renew their licenses every two years, and completion of continuing education coursework may be required. RHIT and RHIA credentials are also good for two years; RHITs must earn 20 continuing education units during that time, while RHIAs need to earn 30 continuing education units .

Clinical Documentation Specialist Salary and Job Outlook

Clinical documentation specialists ensure documentation accuracy and quality in healthcare environments; they have college degrees and experience, along with medical coding, communication, and leadership expertise, and, in 2020, earned a median annual salary of $82,428.

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