Clinical Documentation Specialist

Job Description

REQUIREMENTS

• Education: Bachelor’s Degree (BA/BS) in Psychology, Social Work, or a closely related behavioral health field preferred.
• Knowledge: Basic understanding of psychological terminology and the DSM-5-TR.
• Skills:
• Exceptional command of English grammar and professional writing.
• High proficiency in Microsoft Word and PDF editing software.
• Strong organizational skills and the ability to meet strict 24–48 hour turnaround deadlines.
• Environment: Must have a private, secure home office setup to maintain patient confidentiality.

RESPONSIBILITIES

• Documentation Audit: Review psychological reports (ADHD, Autism, disability, etc.) for completeness, ensuring all required sections (History, Mental Status Exam, Summary) are present.
• Data Verification: Cross-check psychometric test scores (e.g., WAIS, Woodcock-Johnson) against data tables to ensure no transcription errors occurred.
• Compliance Check: Ensure all reports adhere to HIPAA privacy standards and internal company “style guides.”
• Proofreading & Editing: Correct grammar, syntax, and spelling while maintaining the clinician’s original clinical voice.
• Workflow Coordination: Track report status in the EHR system and communicate with licensed psychologists regarding missing information or needed clarifications.

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