
Clinical Documentation Specialist
7 days ago
**Job Summary**
We are seeking a skilled Clinical Documentation Specialist to review and assess patient medical records, ensuring they are complete, accurate, and aligned with the care provided.
This role requires the use of clinical knowledge to analyze documentation — there is no patient interaction involved. The position involves working onsite at our facility, following an evening shift from 6:00 PM to 2:00 AM, 6 days a week.
Key Responsibilities:- Evaluate patient records to ensure clarity, completeness, and consistency in clinical documentation.
- Use clinical judgment to analyze diagnoses, treatments, and care documentation for accuracy.
- Identify documentation gaps, inconsistencies, or ambiguities and flag them for clarification.
- Collaborate with internal teams and provide documentation improvement feedback when required.
- Support compliance with internal standards, HIPAA, and external quality and audit requirements.
- Track documentation trends and assist with internal reviews or quality improvement initiatives.
- Maintain a high level of confidentiality and attention to detail in all documentation processes.
- Work independently with a focus on record review — no direct patient communication involved.
**Qualifications:**
- Bachelor's degree in Nursing, Health Information Management, or a related healthcare field.
- 2+ years of experience in clinical documentation review, medical records, or healthcare quality.
- Strong clinical knowledge and understanding of medical terminology and care workflows.
- Fluent in English (spoken and written) with excellent communication and documentation skills.
- Comfortable working onsite, 6:00 PM to 2:00 AM, 6 days a week (no work-from-home).
- Proficiency in using Electronic Health Record (EHR) systems.
- Certification in Clinical Documentation Improvement (CCDS, CDIP) is a plus but not required.
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