Clinical Documentation Specialist

Complete Care • Maitland, FL

1d

About The Position

We are seeking a detail-oriented and dependable Clinical Documentation Specialist to support our clinical teams by ensuring accurate, timely, and compliant patient documentation. This role is essential to maintaining the integrity of medical records, supporting providers during patient encounters, and upholding documentation standards that contribute to high-quality patient care. The ideal candidate is adaptable, collaborative, and committed to excellence in clinical documentation.
Position Purpose
The purpose of the Clinical Documentation Specialist is to support providers and clinical operations by assisting with the creation, review, and maintenance of clinical documentation. This role helps ensure medical records are complete, accurate, and compliant with regulatory and organizational standards, allowing providers to focus on patient care while maintaining high documentation quality.
Position Summary
The Clinical Documentation Specialist supports high-quality patient care by assisting in the preparation, organization, and review of clinical records. This role involves drafting and updating clinical documents, supporting providers with accurate notetaking, and reviewing charts to ensure compliance, accuracy, and integrity. Responsibilities may evolve based on clinic needs and workflows.

Requirements

• Strong ability to draft, edit, and organize clinical documentation with precision and clarity
• Familiarity with common clinical terminology, procedures, and diagnoses
• High level of accuracy when reviewing and entering patient information, ensuring completeness and consistency
• Strict adherence to HIPAA regulations and patient privacy standards
• Ability to conduct basic chart audits to identify missing, incomplete, or inconsistent documentation
• Clear, professional verbal and written communication with providers and team members
• Flexibility and willingness to adapt to changing documentation workflows and regulatory updates
• Team-oriented mindset, supporting both clinical and administrative functions
• Ability to provide proficient language translation support as needed to facilitate effective communication with patients and staff

Responsibilities

• Assist in drafting, editing, and preparing clinical documentation to support patient care and clinic operations
• Scribe or summarize provider notes during or after patient encounters to ensure timely and accurate documentation
• Participate in systematic reviews and audits of clinical records to maintain accuracy, integrity, and regulatory compliance
• Maintain awareness of and adhere to documentation best practices, regulatory guidelines, and internal policies
• Provide general support for clinical documentation workflows, adapting to evolving processes and priorities

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 251-500 employees