Clinical Documentation Specialist

ABOUT THE ROLE 

The Clinical Documentation Specialist (CDS) supports Hopscotch Primary Care Providers (PCPs) and care teams in comprehensive and targeted chart reviews and chart preparation — to ultimately facilitate efficient and effective medical care for our patients. In addition, this role will partner with clinic leaders to indirectly support daily huddle and monthly clinical documentation review. The CDS is a critical hire to lead our passionate, skilled, and committed team at Hopscotch as we work to achieve our big and important mission.    

This position is fully remote and may have need to travel to clinic locations or team events in Western North Carolina 1-2 times per year. 

WHAT YOU’LL DO   

• Specific responsibilities for this role will include, but are not limited to:  
• Prepare patient charts in advance of scheduled visits, ensuring providers have complete, accurate, and actionable information to address documentation and quality gaps  
• Maintain a comprehensive patient chart within the EHR, including problem lists, relevant past medical history, discharge summaries, and other key documentation 
• Access and review external EHRs to identify documentation or clinical care gaps and incorporate supporting information to enhance chart completeness 
• Identify and request medical records from previous primary care providers or specialists to support care continuity and quality of care 
• Coordinate and contribute to monthly clinical documentation review meetings with supported providers, highlighting documentation gaps, trends, and opportunities for improvement 
• Participate actively in clinic operations, attending relevant meetings and contributing to discussions that impact documentation accuracy and care delivery 
• Engage in bi-weekly clinical documentation specialist cohort meetings to share best practices, align on workflows, and advance documentation initiatives 
• Contribute to continuous improvement efforts, performing other duties as assigned to enhance documentation excellence, provider efficiency, and patient care outcomes 

  

ABOUT YOU   

You would be a great fit for this position if you have a minimum of  1 year of experience in the medical field embedded into an interdisciplinary team, are highly motivated, and the following: 

• Proven experience and ability to build relationships with Providers  
• Proficiency in tracking down and leveraging external resources, such as hospital records and payer data, to support retrospective and prospective accurate documentation  
• Proven ability to learn new topics and demonstrated flexibility  
• Ability to succeed in a fast-paced, ever-changing environment  
• Ease and expertise working with multiple technical systems, including Athenahealth and Excel  
• Self-starter with a high degree of drive, initiative, and follow through  
• Ability to develop, plan, and implement short- and long-term goals  
• A flexible, positive attitude and a team-first approach to working  
• Exceptional interpersonal, written and verbal communication skills  
• Commitment to company vision  

From a cultural perspective, you are:   

• Committed to excellence and bring a growth mindset to everything you do   
• Patient and mission-focused, with a passion for healthcare and service to the providers who deliver healthcare  
• Agile, yet thoughtful and can work effectively in a fast-paced, dynamic environment   
• Constantly seeking ways to simplify and improve how things are done, bringing a positive attitude to challenges   
• Accountable, holding yourself and others to a high standard and seek to support and develop others   
• Willing to roll up your sleeves, bringing a high work ethic and strong collaboration skills to work effectively with people of all backgrounds