Clinical Documentation Specialist-Nurse

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.

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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