Clinical Documentation Specialist

Clinical Documentation Specialist responsible for overseeing the facility's medical recordkeeping and ensuring documentation complies with federal laws. Duties include applying medical terminology to evaluate documents, collecting and updating medical information, verifying accuracy and obtaining missing data, monitoring diagnoses and follow-up entries, interpreting and preparing clinical reports for healthcare professionals and public health officials, ensuring content and storage comply with laws, staying updated on coding guidelines and facility-specific instructions, maintaining patient confidentiality, and contributing as a team player with strong attention to detail and critical thinking. Attendance per company policies; adapt to changing business requirements; emphasis on HIPAA compliance and ongoing professional development.