Clinical Documentation Specialist

Integritycaregroup; Sapulpa (OK); Hybrid; USD 42,000 - 56,000; Full time

Job summary

Integritycaregroup is seeking a Clinical Support Specialist to participate in documenting healthcare records under provider supervision. You will ensure compliance with clinic, state, and national policies while contributing to efficient patient care workflows.

Responsibilities include reviewing AI-generated documentation, preparing records for provider review, and assisting with orders, lab results, and discharge documentation.

Qualifications

• High school diploma or equivalent required.
• Current BLS certification required.
• Healthcare experience preferred.

Responsibilities

• Assist with documenting clinical encounters using EMR and AI tools.
• Review AI-generated notes for completeness and clarify as needed.
• Prepare documentation for provider review and signature.

Skills

PC skills

Medical terminology reading

All shifts

Patient escort by wheelchair

Interpersonal communication

Education

High School Diploma

BLS certification

Job description

Description

Position Summary:

The Clinical Support Specialist will participate in the documentation of healthcare records for patients under the direction of on-staff providers while maintaining compliance with clinic, State, and National policies, procedures, rules, and regulations.

Duties and Responsibilities:

• Support the creation of accurate and timely clinical documentation during patient encounters using AI-enabled documentation tools and the electronic medical record (EMR), including HPI, ROS, physical exam findings, and provider observations.
• Review AI-generated encounter documentation for completeness, clarity, and internal consistency and flag discrepancies or items requiring provider clarification.
• Prepare clinical documentation for provider review and signature.
• Enter and queue laboratory, imaging, medication, and prescription orders for provider review and approval.
• Process and document lab results, diagnostic testing, and provider interpretations within the electronic medical record (EMR).
• Assist with patient discharge workflows, including entering diagnoses, preparing discharge instructions, printing patient paperwork, work notes, and school excuses, and completing discharge documentation in the EMR
• Support patient flow by updating patient status, facilitating timely discharges, and helping reduce door-to-door visit times.
• Communicate with patients regarding wait times, test results, care updates, and provider-directed follow-up information.
• Assist with pharmacy management activities, including updating pharmacy information and supporting prescription processing.
• Manage provider inbox tasks, telephone encounters, patient callbacks, and other routine communications.
• Enter procedure documentation, medication administration records, injection orders, and EKG interpretations as directed by providers.
• Assist clinical staff with laboratory operations and specimen processing when needed.
• Answer incoming clinic phone calls and route requests appropriately.
• Collaborate with providers, nurses, technicians, and administrative staff to improve clinic efficiency and patient experience.
• Serve as a workflow support resource, allowing providers to focus on direct patient care while maintaining timely and accurate documentation.
• Monitor outstanding clinical documentation, orders, results, patient communications, and other provider-directed tasks and facilitate timely completion or escalation to the appropriate team member.
• Additional duties as assigned

Requirements

Education:

• High School Diploma or equivalent.
• Licenses/Certification:
• Must obtain and maintain a current certification in BLS.

Experience:

• Healthcare experience preferred.

Skills:

• PC skills or applicable computer experience.
• Ability to accurately read and write medical terminology.
• Ability to work all shifts.
• Ability to escort or transport patient by wheelchair or stretcher.
• Detail-oriented with excellent interpersonal communication skills.

Working Conditions:

• May be exposed to/occasionally exposed to patient elements.
• Subject to varying and unpredictable situations and interruptions.
• Occasionally subjected to irregular hours.
• Occasional pressure due to a fast-paced environment.
• The position may require lifting, carrying, or pushing equipment or patients.

Physical Requirements:

• Must be able to see with corrective eyewear.
• Must be able to hear clearly with assistance.
• May be exposed to infectious and contagious diseases.
• May be in contact with patients under a wide variety of circumstances.
• Able to handle emergency or crisis situations.
• Will be required to wear protective equipment as necessary.
• Ability to escort or transport patient by wheelchair or stretcher
• Frequently: Sitting, walking, standing.
• Occasionally: Bending, squatting, climbing, kneeling, twisting, lifting, carrying, pushing, traveling.
• Ability to lift 15-20 pounds