Clinical Documentation Specialist

Family Health Center • Worcester, MA

11d

About The Position

The Clinical Analyst supports clinical operations by ensuring accurate and timely management of patient orders, referrals, and clinical results within the electronic health record (EHR). This role plays a critical part in closing the loop on patient care by assisting with order closures, scanning and attaching referral and diagnostic results, generating referral reports, and conducting patient follow-ups as needed.

Requirements

• Associate or bachelor’s degree in health information management, Healthcare Administration, or related field.
• 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).
• Strong analytical, organizational, and problem-solving skills
• Excellent communication and attention to detail
• Ability to manage multiple priorities in a fast-paced clinical environment

Nice To Haves

• Health Benefit Advisor (HBA) and Registered Health Information Technician Certification (RHIT) preferred but not required
• Bilingual preferred.

Responsibilities

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree