Clinical Documentation Specialist

23 hours ago

Gandhinagar, Gujarat, India beBeeScribing Full time ₹ 6,40,000 - ₹ 10,24,000
Job Overview

We are seeking an experienced Medical Scribe Manager to fill this role.

Key Responsibilities:
  • Review and transcribe physician dictation to create clinical notes in EMR/Billing systems.
  • Prepare and assemble medical record documentation/charts for physicians.
  • Ensure medical record compliance by self-documentation attestation.
  • Update patient history, physical exam, and other pertinent health information in the patient's record.
  • Prepare and send all documentation to physicians for review and approval via authentication of detailed data entry and facility-specific procedures.
  • Monitor the duration of basic lab results and screening procedures.
  • Comply with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
  • Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
  • Assign codes to diagnoses and procedures, using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes.
  • Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations.
  • Follow up with the provider on any documentation that is insufficient or unclear.
  • Communicate with other clinical staff regarding documentation.
  • Search for information in cases where the coding is complex or unusual.
  • Receive and review patient charts and documents for accuracy.
  • Review the previous day's batch of patient notes for evaluation and coding.
  • Ensure that all codes are current and active.
Requirements:
  • 3-5 years of experience as a Live Medical Scriber.
  • 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 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.
Benefits:

This role offers a competitive salary and opportunities for professional growth.

Others:

Please note that we are an equal opportunity employer.

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