Clinical documentation improvement specialist vs medical record assistant

The differences between clinical documentation improvement specialists and medical record assistants can be seen in a few details. Each job has different responsibilities and duties. It typically takes 6-12 months to become both a clinical documentation improvement specialist and a medical record assistant. Additionally, a clinical documentation improvement specialist has an average salary of $64,797, which is higher than the $34,870 average annual salary of a medical record assistant.

The top three skills for a clinical documentation improvement specialist include patients, patient care and clinical documentation improvement. The most important skills for a medical record assistant are patients, data entry, and HIPAA.

Clinical documentation improvement specialist vs medical record assistant overview

	Clinical Documentation Improvement Specialist	Medical Record Assistant
Yearly salary	$64,797	$34,870
Hourly rate	$31.15	$16.76
Growth rate	11%	11%
Number of jobs	66,130	91,238
Job satisfaction	-	-
Most common degree	Bachelor's Degree, 44%	Bachelor's Degree, 34%
Average age	45	45
Years of experience	12	12

What does a clinical documentation improvement specialist do?

Clinical documentation improvement specialists are professionals who are involved in the clinical documentation improvement (CDI) program that incorporates the terminology needed to translate a patient's condition into precise codes. These specialists must investigate complex healthcare reimbursement information to ensure that appropriate documentation is provided for proper patient care. They must collaborate with physicians and medical record coding staff so that they facilitate the clinical documentation improvement process. Clinical documentation improvement specialists must also train members of the patient care team about the documentation guidelines for medical records.

What does a medical record assistant do?

A medical record assistant is responsible for the proper documentation of the patients' information and medical records for reference to the attending physician or other medical professionals. Medical record assistants also track the patient's medical treatments and progress, as well as their health insurance details and coverage. They also respond to the patient's inquiries and concerns, including scheduling physician's appointments and updating the patients for any released medical results. A medical record assistant must have excellent communication and organizational skills, categorizing documents, and retrieving files for medical needs.

Clinical documentation improvement specialist vs medical record assistant salary

Clinical documentation improvement specialists and medical record assistants have different pay scales, as shown below.

	Clinical Documentation Improvement Specialist	Medical Record Assistant
Average salary	$64,797	$34,870
Salary range	Between $47,000 And $87,000	Between $28,000 And $43,000
Highest paying City	Madera, CA	Napa, CA
Highest paying state	California	Alaska
Best paying company	Nuance Communications	Nelson Mullins Riley & Scarborough
Best paying industry	Health Care	Government

Differences between clinical documentation improvement specialist and medical record assistant education

There are a few differences between a clinical documentation improvement specialist and a medical record assistant in terms of educational background:

	Clinical Documentation Improvement Specialist	Medical Record Assistant
Most common degree	Bachelor's Degree, 44%	Bachelor's Degree, 34%
Most common major	Nursing	Business
Most common college	Duke University	University of Pennsylvania

Clinical documentation improvement specialist vs medical record assistant demographics

Here are the differences between clinical documentation improvement specialists' and medical record assistants' demographics:

	Clinical Documentation Improvement Specialist	Medical Record Assistant
Average age	45	45
Gender ratio	Male, 15.2% Female, 84.8%	Male, 17.3% Female, 82.7%
Race ratio	Black or African American, 9.5% Unknown, 4.2% Hispanic or Latino, 15.7% Asian, 8.9% White, 60.4% American Indian and Alaska Native, 1.3%	Black or African American, 9.1% Unknown, 4.2% Hispanic or Latino, 16.9% Asian, 8.5% White, 60.0% American Indian and Alaska Native, 1.3%
LGBT Percentage	9%	9%

Differences between clinical documentation improvement specialist and medical record assistant duties and responsibilities

Clinical documentation improvement specialist example responsibilities.

Create documentation education classes to general surgery residents, increasing the leveling of reporting which lead to increase revenues.
Interact directly with physicians to query for more specific documentation and to provide documentation guidelines from ICD-9 and ICD-10 standards.
Prepare, maintain and update clinical documentation ensuring completeness and accuracy of services provide to the patients.
Assign the correct POA status.
Participate in the initiation of the CDIS program.
Train new employees on how to utilize radiology information systems.

Medical record assistant example responsibilities.

Lead special department-wide task force initiative to minimize abuse of Oxycontin prescriptions bill to Medicaid.
Manage and organize all paperwork concerning caregivers and patients; organize filing system; ensure operation of electronic filing systems.
Work with EHR, provide medical records to patients and specialty centers.
Guide department through transition from paper charts to EHR system scan all patient records into database.
Scan documents into electronic medical records system and certify HIPAA compliance
Implement HIPAA guidelines in keeping patient information secure and confidential.

Clinical documentation improvement specialist vs medical record assistant skills

Common clinical documentation improvement specialist skills

Patients, 18%
Patient Care, 13%
Clinical Documentation Improvement, 12%
CCDS, 8%
ICD-10, 7%
CCS, 6%

Common medical record assistant skills

Patients, 37%
Data Entry, 8%
HIPAA, 6%
Patient Care, 4%
Vital Signs, 4%
Medical Terminology, 3%

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Clinical Documentation Improvement Specialist
Clinical Documentation Improvement Specialist vs Medical Record Assistant

Updated January 8, 2025

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