Clinical Documentation Specialist
Complete Care
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
Mid-LevelSenior
About the role
- Support high-quality patient care by assisting in the preparation, organization, and review of clinical records
- Draft and update clinical documents, supporting providers with accurate notetaking and reviewing charts to ensure compliance, accuracy, and integrity
- 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
Requirements
- 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
Benefits
- 500 dollar Sign on Bonus
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentationnotetakingchart auditspatient information accuracydocumentation workflowsregulatory compliancedrafting clinical documentsediting clinical documentsorganizing clinical recordsfamiliarity with clinical terms
Soft skills
communicationteamworkadaptabilityattention to detailclarity in writingprofessionalismsupportivewillingness to learnproblem-solvinglanguage translation