Clinical Documentation Specialist

12 hours ago

Anantapur, Andhra Pradesh, India beBeeClinical Full time ₹ 10,00,000 - ₹ 20,00,000

Job Title: Clinical Documentation Specialist

Job Description:

The role of the Clinical Documentation Specialist plays a vital part in enhancing healthcare provider productivity and clinic workflow optimization.

  • Reviews physician dictation to accurately transcribe clinical notes into electronic medical records and billing systems.
  • Prepares and assembles comprehensive medical record documentation for physicians, ensuring all necessary information is included.
  • Ensures adherence to medical record compliance standards by self-documenting attestation processes.
  • Updates patient history, physical examinations, and other relevant health information within patient charts.
  • Monitors duration of basic lab results and screening procedures to ensure timely follow-up actions.
  • Complies with hospital and medical facility policies, including HIPAA and Joint Commission regulations.
  • Performs various clerical duties and tasks assigned to improve provider productivity and clinic workflow.
  • Assigns accurate diagnoses and procedures codes using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) coding systems.
Required Skills and Qualifications:
  • A minimum of 3-5 years of experience working as a live Medical Scribe.
  • Strong administrative writing skills, including effective communication and reporting techniques.
  • Organizational and time management skills, with ability to prioritize multiple tasks efficiently.
  • Proficient in Microsoft Office applications and typing skills.
  • Excellent professionalism, confidentiality, and organizational abilities.
Benefits:

Candidates must possess strong knowledge of anatomy, physiology, and medical terminology. Familiarity with ICD-X codes and CPT Procedures is also desirable. Skilled individuals in operating various medical record software and hardware, word-processing, and database software programs will be preferred.

Others:

Medical coding or successful completion of a certification program would be advantageous. A Bachelor's degree with a pre-health career track is preferred but not essential. Strong oral and written communication skills are crucial for success in this position.

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