Clinical Documentation Specialist

Job Description

Job Description

Position Summary:

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.

Program Specific Essential Duties and 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.

Qualifications and Education Requirements:

One of the following combinations of education and employment experience must be met to be considered for the position:

Education and Experience

• Associate or bachelor’s degree in health information management, Healthcare Administration, or related field.

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

• 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).

• Bilingual preferred.

• Strong analytical, organizational, and problem-solving skills

• Excellent communication and attention to detail

• Ability to manage multiple priorities in a fast-paced clinical environment

Reporting to:

Director of Clinical Operations

EOE