Clinical Documentation Specialist

Clinical Documentation Specialist

About the Role

We are looking for a dependable and detail-focused Clinical Documentation Specialist to support our providers in delivering outstanding patient care. This team member will work side-by-side with physicians during patient visits, documenting clinical information, assisting with workflow management, and helping ensure a smooth and positive experience for every patient. Role will be similar to a medical scribe.

This opportunity is well suited for individuals interested in healthcare, eye care, medical assisting, or clinical support roles who thrive in a busy patient-centered environment.

Key Responsibilities

• Provide real-time documentation of patient visits within the electronic health record system.
• Capture and record patient concerns, medical histories, examination findings, assessments, and treatment recommendations.
• Support providers by accurately entering orders, prescriptions, referrals, and diagnostic testing requests.
• Prepare exam lanes and verify that all necessary equipment, supplies, and patient information are available prior to appointments.
• Assist in coordinating patient movement throughout the clinic to promote efficient scheduling and timely care.
• Explain testing procedures and post-visit instructions as directed by the provider.
• Maintain accurate, complete, and confidential medical records in accordance with HIPAA guidelines.
• Assist with clinical support duties, including technician-related tasks, when needed.
• Collaborate with providers and staff to ensure high-quality patient care and operational efficiency.
• Perform additional administrative or clinical responsibilities as assigned.

Required Qualifications

• High school diploma, GED, or equivalent education.
• Strong keyboarding, data-entry, and computer navigation skills.
• Excellent organizational abilities with strong attention to detail.
• Effective interpersonal and verbal communication skills.
• Ability to manage multiple priorities in a fast-paced healthcare setting.
• Professional behavior and commitment to exceptional customer service.

Preferred Qualifications

• Previous experience in a medical scribe, ophthalmic technician, optometric technician, healthcare assistant, or medical assistant role.
• Familiarity with electronic health record (EHR/EMR) platforms.
• Understanding of basic medical terminology and clinical documentation.
• Prior exposure to ophthalmology, optometry, or related healthcare specialties.

Preferred Credentials

The following certifications are welcomed but not required:

• Certified Ophthalmic Assistant (COA)
• Certified Paraoptometric (CPO)
• Certified Clinical Medical Assistant (CCMA) or equivalent certification

Work Environment & Physical Requirements

This position is based in a professional healthcare office and requires regular interaction with patients, physicians, and staff. Team members should be comfortable standing, walking, sitting, and using office and clinical equipment throughout the workday. Occasional lifting of up to 50 pounds may be required. Visual abilities, including close-up and distance vision, are necessary for performing job duties effectively.

Additional Information

The responsibilities listed above represent the general nature of this position and are not intended to cover every duty that may be assigned. Team members may be asked to perform additional tasks consistent with business needs. Reasonable accommodations will be provided in accordance with applicable laws.

Our organization may use technology-assisted tools during portions of the recruitment process to enhance efficiency and candidate experience. Every application receives human review, and all employment decisions are made by our hiring team.

Equal Employment Opportunity

We are proud to be an Equal Opportunity Employer committed to creating an inclusive workplace for all employees and applicants. We maintain a tobacco- and vape-free work environment and participate in the federal E-Verify program.