Top 12 Clinical Documentation Specialist Skills to Put on Your Resume

Clinical Documentation Specialists sit at the hinge of care and data. Precise notes, sharp coding, crisp queries—those habits shape patient safety, performance metrics, and fair reimbursement. To stand out, blend technical fluency with calm, clear communication. You’re the steward of the record and the translator of clinical intent.

Clinical Documentation Specialist Skills

1. ICD-10-CM
2. CPT Coding
3. Epic Systems
4. 3M 360 Encompass
5. Medical Terminology
6. HIPAA Compliance
7. AHIMA Standards
8. EHR Proficiency
9. DRG Validation
10. Quality Improvement
11. Interdisciplinary Collaboration
12. Clinical Validation

1. ICD-10-CM

ICD-10-CM is the diagnosis coding system used in the United States to classify conditions and symptoms across care settings. It anchors analytics, risk adjustment, reporting, and the medical necessity story inside the chart.

Why It's Important

Standardized diagnosis coding pulls ambiguity out of the record. Accurate ICD-10-CM lets the clinical picture match the coded picture—cleaner claims, clearer outcomes, stronger quality signals.

How to Improve ICD-10-CM Skills

Build accuracy through rhythm and rigor:

1. Keep pace with updates: Review annual code changes each October and quarterly errata. Refresh tip sheets and crosswalks promptly.

2. Tighten documentation: Coach providers on specificity—acuity, laterality, type, stage, cause, and linkage (e.g., “due to,” “with”).

3. Work the queries: Use clear, compliant queries to resolve gaps and contradictions without leading.

4. Mine the tools: Leverage encoder logic, CDI prompts, and problem list hygiene to prevent drift and duplicates.

5. Audit and recalibrate: Review targeted samples, track error patterns, and convert findings into quick micro-trainings.

Consistency beats speed. Specificity beats vagueness. Every time.

How to Display ICD-10-CM Skills on Your Resume

2. CPT Coding

CPT codes describe procedures and services. They track what was done, by whom, and often why. Clean CPT supports clean claims and accurate utilization data.

Why It's Important

Mismatched CPT creates denials, delays, and distrust. Aligned procedure coding tells the full service story and links to documentation that withstands scrutiny.

How to Improve CPT Coding Skills

Sharpen the edge, then keep it sharp:

1. Follow annual changes: CPT updates typically land each January—practice with new codes, deletions, and guideline tweaks.

2. Master bundling rules: Understand edits, modifiers, and when services are separately reportable.

3. Close the loop with clinicians: Clarify procedure details (approach, laterality, time, complexity) to support precise selection.

4. Build a feedback engine: Routine audits, quick-turn corrections, and brief targeted refreshers prevent repeat errors.

5. Use tech wisely: Procedure pick-lists, templates, and prompts reduce omissions without dumbing down nuance.

Accuracy first, then efficiency. Both matter to revenue integrity.

How to Display CPT Coding Skills on Your Resume

3. Epic Systems

Epic is a widely used EHR that fuses clinical workflows, orders, documentation, coding, and analytics. For CDS work, it’s where the narrative gets built and verified.

Why It's Important

When Epic is configured and used well, the chart reads cleanly. Data flows, queries land, dashboards surface risk, and the bill tells the same story the provider wrote.

How to Improve Epic Systems Skills

Work with the system, not against it:

1. Tune templates and SmartTools: SmartPhrases, SmartLinks, SmartForms—streamline without losing clinical detail.

2. Refine workflows: Map where documentation starts, forks, and finishes. Remove clicks that don’t add value.

3. Exploit reporting: Use reporting workbench and dashboards to spot missed specificity, response lags, and query trends.

4. Partner with super users: Share pain points, pilot tweaks, and roll out improvements with brief, on-the-fly training.

5. Practice in a playground: Use training environments to test updates and new build before go-live.

Small build changes can trigger big gains in documentation quality and speed.

How to Display Epic Systems Skills on Your Resume

4. 3M 360 Encompass

3M 360 Encompass connects CDI, CAC, and coding workflows. It flags documentation gaps, aligns clinical evidence, and supports compliant queries—all in stride with the medical record.

Why It's Important

Right-time prompts and integrated reviews reduce missed specificity, tighten validation, and smooth the handoff from documentation to code assignment.

How to Improve M 360 Encompass Skills

Make the platform work for you:

1. Targeted training: Focus on the features you use daily—prioritization rules, worklists, and query templates.

2. Optimize integrations: Ensure solid EHR connectivity and clear context in the launch points to cut back-and-forth hunting.

3. Standardize queries: Use evidence-backed, compliant language. Keep versions controlled and current.

4. Leverage analytics: Track impact—CC/MCC capture, query rates and response times, DRG shifts, denial trends.

5. Close feedback loops: Share findings with coding, CDI, and IT. Adjust rules when noise drowns out signal.

Precision prompts, not pop-up fatigue. That’s the balance.

How to Display M 360 Encompass Skills on Your Resume

5. Medical Terminology

The shared language of anatomy, physiology, pathology, and procedures. It reduces ambiguity and keeps documentation crisp, consistent, and defensible.

Why It's Important

Terminology mastery prevents misinterpretation and drives accurate code selection, clinical validation, and quality reporting.

How to Improve Medical Terminology Skills

Build it into your daily work:

1. Study in sprints: Focus on organ systems and common diagnoses in your service lines.

2. Use reference sources: Keep medical dictionaries and evidence summaries at arm’s reach.

3. Practice retrieval: Flashcards, quick drills, case reviews—short bursts stick.

4. Apply immediately: Work new terms into queries, education notes, and template updates the same day you learn them.

5. Peer review: Compare interpretations on tricky terms to align team usage.

Language fluency speeds everything else up.

How to Display Medical Terminology Skills on Your Resume

6. HIPAA Compliance

HIPAA sets the guardrails for privacy and security of protected health information. For CDS work, it means documenting thoroughly while protecting access, sharing only what’s needed, and safeguarding every data trail.

Why It's Important

Trust hinges on confidentiality. Breaches bring penalties, reputational harm, and—most importantly—risk to patients.

How to Improve HIPAA Compliance Skills

Make privacy a habit, not a hurdle:

1. Know the rules: Privacy, security, breach notification. Keep pace with policy updates and organizational procedures.

2. Limit access: Role-based permissions, strong authentication, and clean workspace practices.

3. Protect data in motion and at rest: Encryption, secure messaging, approved devices only.

4. Audit yourself: Review access logs and spot-check workflows for inadvertent exposure.

5. Plan for incidents: Clear steps for reporting, containment, and communication—rehearsed, not theoretical.

Privacy-first thinking becomes second nature with repetition.

How to Display HIPAA Compliance Skills on Your Resume

7. AHIMA Standards

Guidance from AHIMA grounds information governance, documentation integrity, data quality, privacy, and coding practices across the continuum.

Why It's Important

Standards pull teams onto the same page. Records become consistent, auditable, and fit for care, compliance, and reporting.

How to Improve AHIMA Standards Skills

Turn policy into practice:

1. Ongoing education: Regular briefings on new practice briefs, coding guidance, and documentation integrity updates.

2. Embed standards in policy: Update procedures, templates, and job aids so the right way is the easy way.

3. Quality checks: Routine audits with measurable criteria; convert findings into rapid-cycle improvements.

4. Cross-team alignment: CDS, coding, compliance, and clinicians agree on definitions and expectations.

5. Document version control: Keep audit trails and change logs to show what changed and why.

Clarity in standards reduces friction everywhere else.

How to Display AHIMA Standards Skills on Your Resume

8. EHR Proficiency

EHR proficiency means you can navigate, document, review, query, and report inside the system quickly and correctly—no wandering, no wasted clicks.

Why It's Important

Better EHR skills equal better data. That means safer care, fewer delays, fewer denials, and clearer metrics.

How to Improve EHR Proficiency Skills

Make it muscle memory:

1. Structured learning: Role-based training with live scenarios beats passive tutorials.

2. Shortcuts and personalization: Favorites, filters, smart tools, and keyboard shortcuts shave minutes off every task.

3. Sandbox practice: Train in non-production to test features and new workflows safely.

4. User groups: Share tips, post quick videos, and swap solutions inside your organization and vendor communities.

5. Measure and iterate: Track time-on-task and error rates, then tweak build and training to close the gaps.

Speed without accuracy is noise. Aim for both.

How to Display EHR Proficiency Skills on Your Resume

9. DRG Validation

DRG validation confirms that the assigned DRG reflects the documented diagnoses, procedures, and resource use. It ties the clinical truth to the coded outcome.

Why It's Important

Right DRG, right payment, right risk profile. It protects against denials and tells an honest story about patient complexity.

How to Improve DRG Validation Skills

Make the clinical lens sharper:

1. Education for specificity: Reinforce criteria for CC/MCC capture, principal diagnosis selection, and causal relationships.

2. Targeted audits: Review high-impact DRGs and diagnoses with frequent shifts or denials. Close gaps fast.

3. Coder–CDS collaboration: Huddles to reconcile discrepancies and align on principal versus secondary assignments.

4. Tech assist: Use CDI and encoder analytics to surface inconsistencies in real time.

5. Escalation pathways: Clear routes for physician advisor review when criteria and documentation diverge.

Validation isn’t nitpicking; it’s narrative accuracy.

How to Display DRG Validation Skills on Your Resume

10. Quality Improvement

QI for CDS zeroes in on documentation processes—what’s missing, what’s muddled, what’s misaligned—and fixes them so the record mirrors reality.

Why It's Important

Better documentation improves patient care, outcome measures, compliance posture, and reimbursement accuracy. It compounds across the enterprise.

How to Improve Quality Improvement Skills

Make improvement continuous, not episodic:

1. Define metrics: Accuracy rates, query response times, CC/MCC capture, denial overturns—track what matters.

2. Audit with intent: Small samples, frequent cadence, rapid feedback. Celebrate corrections that stick.

3. Adopt helpful tech: Real-time prompts and analytics that guide action, not dashboards no one reads.

4. Collaborate relentlessly: Physicians, nurses, coding, case management—shared goals, shared wins.

5. Standardize and spread: When something works, codify it and scale. Keep drift in check.

QI is a habit. Keep it light, frequent, and visible.

How to Display Quality Improvement Skills on Your Resume

11. Interdisciplinary Collaboration

CDS work thrives when clinicians, coders, case management, and quality teams move in sync. Shared understanding, fast clarifications, fewer loose ends.

Why It's Important

Multiple viewpoints catch errors and add nuance. The record gets richer, safer, and more consistent.

How to Improve Interdisciplinary Collaboration Skills

Make teamwork tangible:

1. Set clear touchpoints: Brief huddles, defined SLAs for queries, and named contacts for escalation.

2. Agree on definitions: Align criteria, templates, and phrasing to cut down on rework.

3. Share data: Put simple metrics in front of the team—what’s improving, what’s stuck.

4. Practice communication: Concise, respectful, evidence-backed messages get faster responses.

Collaboration isn’t a meeting. It’s a rhythm.

How to Display Interdisciplinary Collaboration Skills on Your Resume

12. Clinical Validation

Clinical validation confirms that diagnoses in the chart are supported by clinical criteria, exam findings, labs, imaging, and response to treatment.

Why It's Important

It protects against upcoding, denials, and patient safety risks from inaccurate problem lists. It also strengthens the integrity of quality metrics.

How to Improve Clinical Validation Skills

Anchor diagnoses to evidence:

1. Know the criteria: Stay current with clinical practice guidelines and coding guidance for common high-risk conditions.

2. Sharpen queries: Ask concise, non-leading questions that point to missing criteria or conflicting documentation.

3. Audit complex cases: Sepsis, AKI, respiratory failure, malnutrition—validate against accepted standards and facility policy.

4. Use decision support: Reference evidence summaries and internal pathways to inform clarifications.

5. Educate in the moment: Convert recurrent misses into quick, case-based teaching.

Evidence first. Codes follow.

How to Display Clinical Validation Skills on Your Resume