Clinical Documentation & Information Specialist

About This Role

This specialist role supports the integrity of clinical documentation, information management, and compliance across the organization. The ideal candidate will ensure that clinical documentation and related records meet organizational, regulatory, and payer standards for accuracy, completeness, and appropriate use, making a vital impact on young lives and families.

Responsibilities

• Conduct real-time, retrospective, and event-driven reviews of clinical documentation and related records to ensure alignment with organizational standards, medical necessity requirements, coding standards, and regulatory expectations
• Identify inconsistencies, unclear entries, or documentation gaps and initiate appropriate follow-up actions, including documentation queries when needed
• Support corrective action planning and track improvements through follow-up reviews
• Contribute to the development and refinement of documentation standards, workflows, and organization-wide quality and compliance initiatives
• Track and monitor key performance and compliance metrics, including documentation accuracy, query response rates, capture rates, release timeliness, and alignment with diagnoses, reporting standards, and disclosure requirements
• Support compliant release and use of information by ensuring documentation integrity, completeness, and appropriateness for disclosure in response to audits, legal requests, payer reviews, and regulatory inquiries
• Collaborate with clinical, coding, Release of Information (ROI), and compliance teams to resolve documentation, coding, and information management issues
• Communicate clearly and professionally to support timely issue resolution and operational consistency
• Provide guidance to clinical, operational, and administrative teams regarding documentation standards, audit readiness, compliant information disclosure, and compliance expectations
• Ensure documentation and information practices adhere to organizational policies, payer guidelines, and applicable state and federal regulations
• Maintain strict confidentiality and professional standards in all interactions involving patient information
• Stay current with regulatory changes, audit trends, and industry best practices related to clinical documentation integrity, coding, and release of information
• Perform other duties as assigned

Requirements

• Understanding of clinical documentation improvement principles and standards
• Familiarity with state and federal regulations, payer requirements, and compliance standards
• Strong analytical, organizational, and communication skills
• High School Diploma or equivalent
• Current driver’s license for state of residence
• Driving record acceptable by agency standards