Clinical Documentation Specialist

Ascensa Health • Atlanta, GA

2d

About The Position

Ascensa Health is a private, non-profit substance abuse and co-occurring disorder treatment center in Midtown Atlanta. The agency is currently seeking a Clinical Documentation Specialist to ensure client records are accurate, complete, and compliant with HIPAA. regulatory, and legal standards. Responsibilities include auditing electronic health records (EHR), identifying documentation errors or gaps, collaborating with clinicians for corrections, and supporting quality improvement initiatives. This role demands high attention to detail, strong knowledge of appropriate clinical documentation types, and expertise in maintaining confidentiality.

Requirements

• Education: Associate or Bachelors degree in Human Service field (Sociology, Psychology, etc.)
• Knowledge: Strong understanding of clinical documentation, specifically behavioral health documentation such as treatment plans, progress notes, and assessments.
• Technical Skills: Proficiency in EHR systems (preferably Carelogic) and data management software.
• Soft Skills: Strong attention to detail, organization, and communication skills.

Responsibilities

• Auditing & Monitoring: Perform regular audits of electronic medical records to ensure accuracy, completeness, and adherence to regulatory standards.
• Compliance Assurance: Ensure all documentation adheres to HIPAA regulations, licensing standards, and company policies.
• Error Correction: Identify discrepancies, omissions, or inconsistencies in clinical notes and work with staff to rectify them.
• Documentation Improvement: Analyze documentation trends to recommend improvements in data gathering and reporting.
• Reporting: Compile and analyze data to report findings to the management team.

What This Job Offers

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