Clinical Documentation Specialist-Nurse
1st Choice Healthcare
Job Description
Job Description
At 1st Choice Healthcare, we embrace and practice patient-centered care and we strive to provide all of our patients with the best possible medical care. We encourage each patient to take an active role in their healthcare. We believe that in addition to helping patients when they are sick, we can and should help guide them in making healthy choices for preventive care.
1st Choice Healthcare is a non-profit, Joint Commission accredited, Federally Qualified Health Center. We welcome all members of our community, especially those unable to afford care. We are founded and governed by our community.
1st Choice Healthcare is an equal opportunity employer. We are committed to fostering a diverse and inclusive work environment, where all individuals are treated with respect and dignity. We do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, or any other characteristic protected by federal, state, or local law. All employment decisions are based on qualifications, merit, and business needs.
Key Responsibilities:
Review patient records ahead of scheduled visits to ensure completeness and accuracy. Identify and flag missing or incomplete documentation, such as medical history, test results, or referrals. Collaborate with providers, nurses, and administrative staff to gather necessary information. Verify and update patient demographic, insurance, and medical information in the electronic health record (EHR) system. Assist in ensuring compliance with documentation requirements, coding guidelines, and regulatory standards. Communicate with patients as needed to obtain missing information or clarify health history.
Qualifications:
- Licensed Practical Nurse (LPN), Registered Nurse (RN)
- 1-2 years of experience in a clinical setting, with familiarity in reviewing and interpreting medical records preferred.
- Strong organizational and time management skills.
- Excellent communication and interpersonal skills.
- Proficiency in electronic health record (EHR) systems.
- Ability to work independently and as part of a team.
- Knowledge of medical terminology and procedures preferred. Must be qualified in Basic Life Support techniques.
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