Clinical Documentation Specialist

Role Overview

• Assisting with the closure of clinical orders and ensuring appropriate documentation is complete
• Monitoring referral workflows and generating referral status and outcome reports.
• Support audits, regulatory reviews, and compliance requirements related to medical records and referrals.
• Supporting data accuracy, reporting, and quality improvement initiatives.
• Monitor, manage, and assist with the closure of clinical orders to ensure timely completion and proper documentation within the electronic health record (EHR).
• Scan, index, and accurately attach referral, diagnostic, and consult results to corresponding patient orders in the EHR.
• Generate, review, and maintain referral and order status reports to identify outstanding, incomplete, or overdue items.
• Conduct patient follow-ups related to referrals, test results, and care coordination needs, escalating concerns to clinical staff or providers as appropriate.
• Communicate with providers, clinical teams, and external offices to obtain missing results or clarify referral outcomes.
• Ensure data accuracy, completeness, and compliance with organizational, regulatory, and program-specific standards.
• Support quality improvement initiatives by identifying workflow gaps and recommending process enhancements related to referrals and order management.
• Maintain confidentiality and always comply with HIPAA and organizational privacy policies.

Requirements

• Associate or bachelor’s degree in health information management, Healthcare Administration, or related field.
• Health Benefit Advisor (HBA) and Registered Health Information Technician Certification (RHIT) preferred but not required
• A minimum of 2 years of relevant healthcare experience.
• Experience working with EHR systems and medical records management
• Knowledge of referral workflows, prior authorizations, and healthcare regulations
• Strong written and verbal communication skills, excellent computer skills (Microsoft Word, Excel, and Outlook).
• Bilingual preferred.
• Strong analytical, organizational, and problem-solving skills
• Excellent communication and attention to detail
• Ability to manage multiple priorities in a fast-paced clinical environment.