Clinical Documentation Specialist
Complete Care
full-time
Posted on:
Location Type: Remote
Location: United States
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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 & Tools
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