Clinical Documentation Specialist

Job Summary

Clinical Documentation Specialist is responsible to oversee the facility's medical recordkeeping practices. In this role, Clinical Documentation Specialist is responsible for ensuring that clinical documentation complies with federal laws, provide feedback in medical recordkeeping practices, and analyzing medical information.

Essential Duties and Responsibilities

1. Applying knowledge of medical terminology and procedures to evaluate clinical documents.
2. Collecting medical information from healthcare providers and updating medical records.
3. Verifying the accuracy of patient medical information and obtaining missing information.
4. Monitoring diagnoses, treatments, and follow-up entries in medical records.
5. Interpreting and preparing clinical reports for healthcare professionals and public health officials.
6. Ensuring that the content and storage of medical documents comply with federal laws.