Clinical Documentation Specialist



The Clinical Documentation Specialist is responsible for optimizing internal controls, including social service programs that  cover  SNAP and behavioral health service. The Documentation Specialist will review and edit clinical documentation and or applications for SNAP benefits to ensure compliance based on program specification for services, coding accuracy, revenue authorization or benefit for services. In addition to optimizing efficiencies and ensuring positive patient outcomes by achieving metric goals via auditing standards.


  • Main contact to audit streamline patients into outpatient programs. Assists with completing review and with documentation completion and authorizations
  • Creates weekly reports, maintains and tracks intake documentation and authorizations to meet medical necessity and services specifications
  • Properly tracks and follows up with direct care staff documentation
  • Distributes all finalized documentation to appropriate staff
  • Provides clinically-based concurrent review of outpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnoses and procedures
  • Coordinates patient’s health records and assists in treatment coordination
  • Assists with maintaining and establishing standards for best practices including intake policies and procedures, assessments, treatment plans, discharge plans, trains employee on best practices and quality assurance measure
  • Coordinates with Healthcare Auditing Coordinator
  • Coordinates patient’s health records and assists in treatment coordination
  • Audits records and trains staff on compliance measures and creates training materials
  • Assists in training and development of new and ongoing staff
  • Ensures documentation accurately reflects the quality of care, the severity of illness and risk of mortality to support correct coding, reimbursement, and quality initiatives
  • Works in collaboration with all departments to ensure compliance with medical necessity and services specifications
  • Follows Operating Principles of Lamour Clinic when completing all tasks
  • Adheres to the system and department compliance policies, and any applicable laws and regulations. Performs other duties as assigned
  • Keep Program Director informed of potential and/or actual problems identified during the review process, concurrent progress and operation of the program
  • Perform initial case reviews, follow up reviews and queries based on program standards
  • Has a strong working knowledge of patient safety indicators, healthcare regulations, reimbursement and documentation requirements
  • Maintains professional competency by keeping abreast of new changes within the industry including coding clinics, advancements in medical treatment, and guidelines


  • Experience working in a fast-paced environment
  • Excellent verbal, written and interpersonal communication skills
  • Detail-oriented Excellent training skills
  • Knowledge of document control policies and practices
  • Ability to learn new software/systems quickly
  • Excellent computer skills
  • Highly adaptable and detail oriented
  • Work well within a team
  • Have an outstanding work ethic


  • $20 – $25 per hour productivity  rate applies depending on experience
  • QSEHRA Health Reimbursement Plan, eligibility at 90 days of full-time employment (32 Hours a week)
  • Paid Federal Holidays
  • Paid Time Off; accrual based, eligible at 120th day of full-time employment (32 Hours a week)
    • 5 (40 Hours) Sick Days
    • 2 Personal Days
    • 5 (40 Hours) Vacation Days
  • 401k available.
  • Flexible Schedule
  • Must be willing to be on call weekdays and weekends over phone
  • Must be able to work in the late afternoons and evenings until 8:15pm and some weekends.
  • Educational Stipends with partnering colleges available

Location: Randolph, MA

Job Type: Full-time

Program: Intake Department

Department: Direct Care Programs

Age group: All ages



  • Social Work Master’s degree or equivalent clinical healthcare compliance and education
  • Experience as an archivist or documentation specialist, preferably with intake assessments, treatment planning, obtaining authorizations for billing within healthcare environment, with 1 years of experience BS or a BA, or pursuing of experience with MSW or MA OR be willing to be trained
  • Current clinical degree or license in Massachusetts preferred
  • Thorough knowledge of medical necessity and services specifications behavioral health outpatient programs
  • Strong computer skills and ability to learn various software packages
  • Detail-oriented skills with the ability to organize and prioritize workload
  • Previously demonstrated ability to achieve results by holding self-accountable
  • Strong written, verbal and electronic communications skills.
  • Ability to work with and positively influence a variety of personalities and diverse work styles
  • Must be Culturally and Linguistically competent; Bilingual a plus: Haitian Creole, Portuguese Creole, Spanish, Vietnamese, Chinese or Cambodian

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