What Does a Clinical Document Specialist Do? Plus Outlook and Salary

By Indeed Editorial Team

Published December 14, 2021

The Indeed Editorial Team comprises a diverse and talented team of writers, researchers and subject matter experts equipped with Indeed's data and insights to deliver useful tips to help guide your career journey.

Clinical document specialists play an important role in managing a medical facility's paperwork. Those who work in this role are responsible for organizing important medical documents for the use of health care professionals. Understanding the role of a clinical document specialist can help you decide if you want to pursue this career path. In this article, we explain what a document specialist is, provide a detailed list of steps for how to become one, explore the skills this position often requires and discuss the salary and job outlook of this profession.

What is a clinical document specialist?

A clinical document specialist is a professional in the health care field who manages the information and required documents for each patient at a clinic. They're typically in charge of keeping a patient's medical information confidential according to industry guidelines. Clinical document specialists ensure that the medical professionals involved in a patient's treatment have sufficient and updated details regarding their health. Some of their responsibilities include reviewing medical records and documenting the necessary information to provide a full analysis of a patient's status. A clinical document specialist also communicates with other departments to correct missing or conflicting data.

Related: 64 Clinical Documentation Specialists Interview Questions

What does a clinical document specialist do?

A clinical document specialist is responsible for using their knowledge of medical terminology and procedures to evaluate clinical documents for accuracy. They often keep medical records updated by collecting information from health care providers. These professionals monitor new entries in documentation regarding diagnoses and treatment plans. Other duties of a clinical document specialist may include:

  • Interpreting clinical reports for their colleagues

  • Sorting and locating documents

  • Ensuring the correct storage of paperwork

  • Validating diagnosis codes

  • Meeting with medical stakeholders

  • Training staff members in medical record-keeping policies

  • Entering document queries into a database

  • Tracking reimbursements from insurance

Related: How To Become a Successful Document Specialist

How to become a clinical document specialist

Here's a list of five steps that you can follow when trying to become a clinical document specialist:

1. Earn a degree

Many clinical document specialists positions require candidates to have a degree in a related field. While some employers may only require you to have an associate's degree, others may prioritize candidates with a bachelor's degree. Completing your bachelor's degree may help you find more opportunities for employment or advancement in your field. It's up to you to determine whether you want to earn a two-year associate's degree or a four-year bachelor's degree.

Consider earning your degree in health information management, care administration, public health, health services or a patient care field like nursing. You might take courses in pharmacology, data management, patient assessment, professional ethics and health care computer information systems. These degree paths can provide you with a foundational knowledge of the health care field, biology, medical terminology and the billing and coding process.

2. Pursue a related role

Before pursuing a role as a clinical document specialist, it's often beneficial to spend some time working in a related medical position. Consider applying for a front-desk job in a health care office setting. You might also spend some time working as a nurse if you have the required education. Many clinical document specialist roles require professionals to have two to five years of experience in a similar position.

3. Gain experience

Continue working in your entry-level medical role to gain knowledge and skills that can assist you as a clinical document specialist. For example, you might gain experience in a role where you learn medical coding practices. This can help you earn a position as a clinical document specialist, as employers often look for candidates with knowledge of different coding systems. You can also practice maintaining the security of patient records, coding medical information and organizing databases. Or, as a nurse, you might gain familiarity with collecting medical histories and communicating with patients.

4. Become certified

Earning a certificate in a related field can help your career as an aspiring clinical document specialist. Certification requirements for clinical document specialists may vary depending on the state they work in, so be sure to research the requirements for your location. Most certificate programs require you to complete an exam to graduate. As a graduate of a health information technology associate's program, one of your options is to pursue a Registered Health Information Technician certification. The American Health Information Management Association is in charge of this certificate program.

If you have your bachelor's degree in health information management, you might become certified through the Registered Health Information Administrator program. These certification options can teach you advanced principles of anatomy, computer technology, physiology and privacy laws to help you accomplish your responsibilities as a clinical document specialist.

Please note that none of the organizations mentioned in this article are affiliated with Indeed.

5. Apply for clinical document specialists positions

After meeting the educational and experience requirements, you can start searching for a role as a clinical document specialist. Start by creating a resume that emphasizes your work experience and document management skills. You might look for available positions in your field on job boards or through your professional connections. Be sure to reference the job description when customizing your resume and other application materials to ensure you include the necessary elements.

Related: Clinical Documentation Improvement: What You Need To Know

Skills needed to become a clinical document specialist

Below are some skills that you may need to become a clinical document specialist:

  • Organization: Clinical document specialists often rely on their organizational skills to manage paperwork for several patients at once. This allows them to keep track of which documents belong to which cases and provide doctors with the appropriate records.

  • Communication: Communication skills are necessary for clinical document specialists to convey information to patients and doctors. This helps them remain professional when communicating with a variety of people in different roles.

  • Empathy: Because clinical document specialists usually interact with sick patients, they need empathy to understand their situations. This allows them to communicate with patients using kindness and patience.

  • Computer: A clinical document specialist typically uses computer software to maintain patient records. This requires them to have excellent computer skills to ensure they enter information correctly.

  • Attention to detail: Clinical document specialists rely on their attention to detail to identify problems with medical documents. This helps them ensure that they catch every mistake, even minor ones.

Work environment for clinical document specialists

Clinical document specialists usually work in health care centers such as hospitals, private practices, dentist offices, psychiatric offices and medical billing centers. These professionals may also find employment in research facilities, university laboratories and insurance companies.

Related: 6 Top Careers in Health Information Management

Salary and job outlook for clinical document specialists

Your salary as a clinical document specialist may vary depending on the job's location and the hiring organization. Although Indeed doesn't have specific salary information for clinical document specialists, they have data for document specialists, a very similar job title. The current national average salary for document specialists is $43,434 per year.

While there isn't job outlook information for clinical document specialists specifically, the U.S. Bureau of Labor Statistics predicts the employment of medical records and health information specialists to grow 9% through 2030. This rate is about as fast as average for all occupations. The BLS specifies that the extended use of electronic health records may drive an increase in the employment of medical records and health information specialists. These projections show a demand for professionals familiar with document management in all areas of the health care industry, alluding to continued demand for clinical document specialists.

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