
Careers in Medical Documentation
1 day ago
This role is pivotal to our organization, requiring a seasoned Healthcare Documentation Specialist to collaborate with healthcare providers and utilize advanced technologies to optimize their workflow.
Key Objectives of this Position:
- Review physician dictations and accurately transcribe clinical notes into electronic medical records and billing systems.
- Prepare and assemble comprehensive medical documentation and charts for physicians, ensuring compliance with regulatory requirements.
- Guarantee accurate and up-to-date patient information by reviewing and updating patient history, physical exams, and other pertinent health data in the patient chart.
Responsibilities and Requirements:
- Transcribe complex physician dictations into clear and concise clinical notes.
- Prepare high-quality medical record documentation and charts for physicians.
- Ensure strict adherence to hospital and medical facility policies, including HIPAA and Joint Commission regulations.
- Assign precise diagnostic and procedural codes using ICD and CPT coding systems.
- Effectively communicate with clinical staff regarding documentation and medical procedures.
Essential Skills and Qualifications:
- 3-5 years of experience as a Medical Scribe or Healthcare Documentation Specialist.
- Advanced administrative writing skills.
- Reporting and analytical skills.
- Exceptional organizational and time management abilities.
- Accurate record-keeping and attention to detail.
Our ideal candidate will possess in-depth knowledge of anatomy, physiology, and medical terminology, along with familiarity with ICD-10 codes and CPT procedures. They should also be proficient in operating various medical record software and hardware, word-processing, and database software programs.
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