Clinical Data Coordinator

2 days ago

Amrāvati, Maharashtra, India beBeeDocumentation Full time US$ 60,000 - US$ 95,000
Medical Documentation Specialist

The Medical Documentation Specialist plays a critical role in supporting the healthcare team by accurately and efficiently documenting patient information.

This position is ideal for individuals with excellent writing skills, attention to detail, and strong communication skills.

  • Reviews physician dictation and transcribes to clinical notes in electronic medical record systems.
  • Prepares and assembles medical record documentation/charts for physicians.
  • Ensures medical record compliance by self-documentation attestation.
  • Updates patient history, physical exam, and other pertinent health information in the patient's medical record.
  • Prepares and sends all documentation to physicians for review and approval via secure authentication processes.
  • Monitors the duration of basic lab results and screening procedures.
  • Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission regulations.
  • Performs other administrative duties and tasks to improve provider productivity and clinic workflow as assigned.
  • Assigns codes to diagnoses and procedures, using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes.
  • Ensures accuracy and sequencing of codes in accordance with government and insurance regulations.
  • Follows up with providers on any documentation that is insufficient or unclear.
  • Communicates with other clinical staff regarding documentation and coding requirements.
  • Searches for information in cases where the coding is complex or unusual.
  • Reviews patient charts and documents for accuracy and completeness.
  • Evaluates and updates previous day's batch of patient notes for coding and documentation purposes.

Requirements:

  • 3-5 years of experience as a Medical Scribe
  • Administrative writing skills
  • Reporting skills
  • Organizational skills
  • Record-keeping
  • Microsoft Office skills
  • Professionalism, confidentiality, and organization
  • Typing
  • Solid oral and written communication skills
  • Education, Experience, and Licensing Requirements:
  • Medical coding certification or successful completion of a certification program
  • Bachelor's degree with pre-health career track preferred
  • Strong knowledge of anatomy, physiology, and medical terminology
  • Familiarity with ICD-X codes and CPT Procedures
  • Skilled in operating various medical record software and hardware, word-processing, and database software programs

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