Clinical Documentation Specialist

We are seeking a highly organized and detail-oriented Clinical Documentation Specialist to support the clinical operations of a home care agency.

This role focuses on reviewing and maintaining patient documentation updating clinical information in HHAeXchange and ensuring records are accurate complete and processed promptly.

This is a non-clinical administrative position. No nursing license or healthcare certification is required.

• Review and process clinical and nursing documentation
• Enter and update patient information accurately in HHAeXchange
• Maintain Plans of Care (POCs) and related patient records
• Enter diagnoses medications allergies care requirements and other clinical information
• Review documentation for accuracy completeness and missing information
• Ensure records are processed promptly according to established procedures
• Research missing physician or healthcare provider information when needed
• Contact provider offices to obtain missing documentation or information
• Maintain accurate and organized patient records
• Follow HIPAA requirements and maintain strict patient confidentiality

• Strong attention to detail and accuracy
• Excellent data entry and organizational skills
• Ability to follow detailed processes and instructions
• Comfortable working with medical terminology and patient information
• Strong computer skills and ability to learn new systems quickly
• Good written and verbal English communication skills
• Ability to work independently and manage time-sensitive tasks
• Understanding of patient confidentiality and HIPAA requirements

• Healthcare home care or medical administration experience
• Clinical documentation or medical data entry experience
• Experience with HHAeXchange
• Familiarity with Plans of Care (POCs)
• Knowledge of medical terminology diagnoses and medications
• Experience communicating with physician or healthcare provider offices

Medical or home care experience is preferred but not required.