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Clinical Documentation Specialist
Job in
Worcester, Worcester County, Massachusetts, 01609, USA
Listed on 2026-02-16
Listing for:
Family Health Center of Worcester
Full Time
position Listed on 2026-02-16
Job specializations:
-
Healthcare
Healthcare Administration, Health Informatics
Job Description & How to Apply Below
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 SpecificEssential 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.
Education Requirements:
One of the following combinations of education and employment experience must be met to be considered for the position:
- 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
Director of Clinical Operations
EOEMonday-Friday; 8:30am
-5:00pm.
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