Clinical Documentation Specialist Resume Example & Writing Guide

Use this Clinical Documentation Specialist resume example and guide to improve your career and write a powerful resume that will separate you from the competition.

Clinical documentation specialists are the gatekeepers of medical records. They’re responsible for ensuring that patient information is recorded accurately and completely to avoid insurance scams, malpractice lawsuits, and other issues.

Because clinical documentation specialists work with sensitive information, they’re often required to sign confidentiality agreements. And because they’re tasked with helping healthcare organizations comply with industry regulations, they often need to have a strong understanding of HIPAA guidelines.

Here are some tips and an example to help you write a fantastic clinical documentation specialist resume that will get you noticed by hiring managers everywhere.

David Moore
Chicago, IL | (123) 456-7891 | [email protected]

Clinical documentation specialist with more than 10 years of experience in the medical field. Proven ability to improve patient care and satisfaction by ensuring accurate and complete medical documentation. Expertise in physician education, chart reviews, and audits.

University of Illinois at Chicago Jun '10
B.S. in Health Information Management
Harold Washington College Jun '06
A.A.S. in Health Information Technology
Company A, Clinical Documentation Specialist Jan '17 – Current
  • Assisted with the development of clinical documentation for medical necessity and CPT coding accuracy, reducing denials by over $1 million annually.
  • Provided training to physicians on proper documentation practices resulting in a 100% compliance rate among all providers.
  • Managed physician’s electronic health records (EHR) accounts including account setup, maintenance, and termination as well as troubleshooting issues related to EHR access or functionality.
  • Trained staff on proper charting procedures which resulted in an increase of 99% in charting quality control metrics such as legibility and completeness.
  • Developed new processes that streamlined workflow within the department increasing efficiency by 20%.
Company B, Clinical Documentation Specialist Jan '12 – Dec '16
  • Worked with the medical records department to ensure that all patient information was up-to-date and accurate
  • Ensured that all insurance claims were submitted within 24 hours of a patient’s appointment
  • Created an electronic system for tracking appointments, which increased efficiency by 15%
  • Maintained a filing system for over 1,000 patients’ documents and correspondence
  • Collaborated with management on ways to improve workflow and increase productivity
Company C, Medical Records Clerk Jan '09 – Dec '11
  • Maintained medical records in accordance with HIPAA regulations and company policies.
  • Filed and retrieved medical records as requested by patients, physicians, and other healthcare professionals.
  • Scanned and indexed medical records into the electronic medical record system.
  • Registered Nurse License
  • Certified Professional Coder (CPC)
  • Certified Clinical Documentation Specialist (CCDS)

Industry Knowledge: ICD-10, CPT, E/M, Medical Terminology, Current Procedural Terminology
Technical Skills: Epic, Cerner, Allscripts, McKesson, Meditech, Eclipsys
Soft Skills: Communication, Teamwork, Attention to Detail, Critical Thinking, Leadership, Problem Solving

How to Write a Clinical Documentation Specialist Resume

Here’s how to write a clinical documentation specialist resume of your own.

Write Compelling Bullet Points

When you’re writing bullet points, it can be tempting to simply list your responsibilities. But that’s not enough to make a strong impression. Instead, you should use your bullet points to demonstrate your value by highlighting your accomplishments, skills, and results.

For example, rather than saying you “conducted patient assessments,” you could say you “conducted patient assessments and identified opportunities for clinical improvement in patient care resulting in a 10% increase in patient satisfaction ratings.”

The second bullet point paints a much clearer picture of what you did and the results of your work. And that’s what hiring managers want to see!

Identify and Include Relevant Keywords

When you apply for a job, your resume is likely to be scanned by an applicant tracking system (ATS) for certain keywords. These programs look for specific terms related to the job opening, like “patient care” or “clinical documentation” in order to determine whether your skills and experience are a match. If your resume doesn’t include enough of the right keywords, the ATS might discard your application before a human ever sees it.

To increase your chances of getting noticed, use this list of clinical documentation specialist keywords as a starting point and make sure to include them throughout all sections of your resume:

  • Electronic Medical Record (EMR)
  • Healthcare
  • Medical Terminology
  • Medical Billing
  • U.S. Health Insurance Portability and Accountability Act (HIPAA)
  • Hospitals
  • Medical Records
  • Healthcare Management
  • Data Entry
  • Vital Signs
  • Healthcare Information Technology (HIT)
  • Urgent Care
  • Healthcare Information Management
  • Physician
  • Appointment Scheduling
  • Pediatric Advanced Life Support (PALS)
  • Electronic Medical Record Implementation
  • Case Management
  • Inpatient Care
  • Patient Safety
  • Basic Life Support (BLS)
  • Microsoft Access
  • Documentation
  • Nursing
  • Customer Service
  • Clinical Research
  • Laboratory Data
  • Medical Education
  • Cardiopulmonary Resuscitation (CPR)
  • Standard Operating Procedure (SOP)

Showcase Your Technical Skills

As a clinical documentation specialist, you are responsible for ensuring that the medical records of patients are accurate and up to date. To do this, you need to be familiar with a variety of software programs and systems. Some of the most commonly used programs are electronic health records (EHR) software, medical coding software, and transcription software. Additionally, you need to be familiar with the ICD-10 and CPT coding systems. So if you have experience with any of these programs or systems, be sure to list them on your resume.


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