Clinical Documentation Specialist Jobs in Pennsylvania

Do you enjoy staying organized, working with important healthcare information, and helping clinical teams stay prepared?

Are you someone who pays close attention to detail and takes pride in making sure information is accurate, organized, and easy to find?

If so, you may be the perfect fit for our One Senior Care family of businesses, including LIFE-NWPA, Mountain View PACE, and Buckeye PACE.

Job Summary:

As a Medical Assistant, Clinical Documentation Support, you’ll help prepare provider-facing documentation for PACE Participants by organizing existing medical records and other approved clinical information. You’ll gather records, prepare documentation support materials, manage work queues, and help ensure providers have the information they need before scheduled visits.

This position is ideal for someone who is organized, detail-oriented, and comfortable working with electronic medical records, medical coding, and provider documentation. You must have experience with medical coding with a strong CC focus and understand how providers document clinical conditions in the medical record. You’ll work closely with providers, the CDI Nurse, Medical Records, Clinical Operations, and other team members in a collaborative environment focused on accurate documentation and quality Participant care.

Schedule:

Remote, Monday through Friday, 8:00 AM to 5:00 PM. This is a full-time remote position and requires reliable availability and connectivity during scheduled work hours.

Benefits:

• 9 Paid Holidays
• PTO starting at 3 weeks + 1 day per year (accrued from date of hire for full-time employees)
• Medical, Dental, & Vision
• Free Life and AD&D Insurance Plan
• Health Savings and Flexible Spending Accounts
• Short Term Disability Insurance
• Group Voluntary Term Life Insurance for Employee, Spouses, and Dependents
• Paid Parental Leave
• Tuition Reimbursement and Paid Training Opportunities
• Retirement Plan with company annual match
• Mileage Reimbursement at annual IRS rate as applicable

Duties/Responsibilities:

• Gather and organize existing medical records and approved clinical documentation for provider review.
• Prepare provider-facing documentation packets and templates before scheduled Participant visits.
• Review assigned work queues and retrieve approved reports and supporting documentation.
• Organize hospital, emergency department, skilled nursing facility, specialist, laboratory, imaging, medication, vital sign, assessment, and care plan information.
• Ensure documentation materials are complete, factual, organized, and available within established timelines.
• Track missing records and follow up through approved channels.
• Maintain accurate work queues, preparation trackers, and provider visit readiness logs.
• Track documentation status and route items to the appropriate provider or CDI Nurse.
• Work collaboratively with providers, Medical Records, Clinical Operations, CDI Nurses, scheduling, and other support teams.
• Escalate unclear, inconsistent, complex, or audit-sensitive information to the appropriate clinical leader.
• Use approved templates and neutral language when preparing documentation support materials.
• Assist with follow-up tracking after provider visits.
• Participate in quality improvement, workflow development, and training activities.
• Maintain Participant confidentiality and follow HIPAA and organizational policies.
• Other duties as assigned.

Everyone’s journey is unique. Even if you haven’t done it all, your dedication to learning and helping others is what counts. With our training, mentorship, and career development programs, we’ll help you grow and succeed.

What Makes You a Great Fit:

• Organized, dependable, and highly detail-oriented.
• Strong understanding of medical coding with a CC-focused approach.
• Understands provider charting and how clinical conditions are appropriately documented in the medical record.
• Comfortable reviewing provider documentation and identifying missing or incomplete information for appropriate review.
• Comfortable working with confidential healthcare information.
• Able to manage multiple priorities, deadlines, and work queues.
• Strong written and verbal communication skills.
• Able to work independently while also collaborating with a larger clinical team.
• Comfortable using electronic medical records and learning new technology.
• Able to recognize when information needs to be escalated to a provider, CDI Nurse, or clinical leader.
• Understands the importance of maintaining neutral, factual documentation.
• Strong computer skills, including Microsoft Office, Outlook, Excel, and Teams.
• CPR and First Aid Certification (or willingness to obtain after hire, we’ll provide the training!).

Education and Experience:

• High School Diploma or GED required.
• Medical Assistant training, diploma, certificate, or equivalent healthcare administrative or clinical support experience preferred.
• Previous medical coding experience with a strong CC focus required.
• Experience reviewing provider charts and understanding provider documentation practices required.
• Experience working with electronic medical records required.
• Experience in medical records, healthcare administration, clinical documentation, or provider support preferred.
• Experience working with the frail and elderly population, PACE, geriatrics, or value-based care is a plus.

Physical Requirements:

• Must be able to sit and work at a computer for extended periods
• Must be able to remain focused and attentive throughout the workday
• May be subject to frequent interruptions and changing priorities
• Must be able to use standard office and computer equipment
• When working on-site, must be able to move throughout the facility as needed

Join Us!

At One Senior Care, you’ll be part of a compassionate team that makes a tangible difference in seniors’ lives — working together to keep participants safe, healthy, connected, and at home.

One Senior Care is an Equal Opportunity Employer. Employment is contingent upon successful completion of required background checks, health and safety screenings, and any clearances required for healthcare programs.