Want a Career Change? How to Become a Clinical Documentation Spe - TulsaCW.com: TV To Talk About | The Tulsa CW

Want a Career Change? How to Become a Clinical Documentation Specialist


Clinical Documentation Specialist

Do you enjoy working with data and gathering information? Looking for a healthcare career that doesn’t require a medical degree? Luckily, you don’t have to attend med school to work in this field.

Nowadays, there are dozens of high-paying healthcare jobs that you can get without a medical degree.

For example, you can become a clinical documentation specialist. The median salary for this role ranges between $50,000 and $96,000 per year, depending on your experience and location.

Clinical documentation specialists (CDIs) are in charge of patient records. They review and organize them, check medical codes, and create detailed reports for the clinical staff. They’re also responsible for HIPPA compliance and may perform administrative tasks.

As a CDI specialist, it’s critical to have excellent organizational and analytical skills. You also need to be detail-oriented and have in-depth knowledge of medical coding.

But what does it take to land a job in this field? Most importantly, how to get started? Read on to find out!

What Is a Clinical Documentation Specialist?

As a CDI specialist, you’ll act as an intermediary between healthcare providers and clinical coders. You will work with computer programs to check, report, and interpret patient data.

Those who choose this career path collect medical information and enter it into computer databases. They analyze patient records, identify inconsistencies, and develop action plans for process improvements.

The day-to-day responsibilities of a CDI specialist depend largely on the job requirements and may include:

  • Evaluate treatment plans, lab results, and other clinical documents
  • Keep patient records in proper order
  • Create reports and present them to the clinical staff and public health officials
  • Identify health-related patterns
  • Ensure all medical records are in compliance with the federal laws
  • Perform research, educational, and administrative tasks
  • Identify opportunities for documentation improvement
  • Attend meetings and provide feedback on outstanding issues
  • Educate healthcare providers and nurses on documentation guidelines and regulations

Feeling confused? That’s perfectly normal.

Don’t fret, though. You will undergo rigorous training and learn everything you need to become a clinical documentation specialist.

Educational Requirements and Must-Have Skills

This job doesn’t require a medical degree. However, you need to be familiar with medical terminology.

Most employers prefer candidates with an Associate’s or Bachelor’s degree in nursing and/or health information technology. Having strong coding skills is a must.

This profession is regulated by the Association of Clinical Documentation Integrity Specialists (ACDIS). The organization offers several types of certifications.

These training programs will give you a competitive advantage in the job market and expand your knowledge.

In addition to industry-specific training, CDI specialists need strong interpersonal and leadership skills. Being a good communicator is essential. Candidates with an analytical mindset have higher chances of success.

Build a Successful Career as a CDI Specialist

As a clinical documentation specialist, you’ll work closely with physicians and other medical professionals. Therefore, it’s important to have a strong understanding of clinical conditions and procedures.

In this role, you’ll work in a fast-paced environment. You need to keep up with the ever-changing laws and learn medical terminology.

For starters, take the steps needed to get your degree. Next, consider enrolling in an internship to hone your skills and gain experience. Connect with other industry professionals and focus on building your network.

In the meantime, browse our Personal Finance section to see how you can grow your income, qualify for a student loan, and make smart investments!

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