Summary of duties: The Clinical Documentation Specialist supports high-quality patient care by assisting in the preparation, organization, and review of clinical records. This role involves drafting and updating clinical documents, supporting providers with accurate notetaking and reviewing charts to ensure compliance, accuracy, and integrity. Responsibilities may evolve based on clinic needs and workflows.
Supervision received: Compliance Director & Fleet Manager Duties & Essential Functions: Reasonable accommodation may be made to enable individuals with disabilities to perform job-related functions.
- Assist in drafting and preparing various clinical documents to support clinical care and operations
- Scribe or summarize provider notes during or after patient encounters to ensure documentation is timely and accurate
- Participate in systematic reviews or audits of clinical records to help maintain accuracy, integrity, and compliance with applicable standards
- Maintain awareness of and adhere to documentation best practices, regulatory guidelines, and internal policies
- Provide general support for documentation workflows, which may shift based on evolving clinical processes and priorities
Skills & Expectations:
- Strong ability to draft, edit, and organize clinical documentation with precision and clarity
- Familiarity with common clinical terms, procedures, and diagnoses used in patient care
- High level of accuracy in reviewing and entering patient information, ensuring consistency and completeness in records
- Adherence to HIPAA regulations and policies governing patient privacy and documentation standards
- Ability to conduct basic chart audits to identify, missing, incomplete, or inconsistent documentation
- Clear and professional verbal and written communication with team and providers
- Willingness to adjust to evolving documentation processes, workflows, and regulatory updates
- Works as part of a team, supporting both clinical and administrative workflows
- Ability to deliver proficient language translation support as needed or applicable to ensure effective communication with patients and staff
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