Clinical Document Coordinator

11 hours ago

Alwar, Rajasthan, India beBeeMedicalDocumentation Full time US$ 90,000 - US$ 1,10,000

Medical Documentation Specialist Job Summary

We are seeking a Medical Documentation Specialist to join our team. As a key member of our healthcare team, you will be responsible for accurately and efficiently documenting patient information in their medical records.

Responsibilities:

  • Review and transcribe physician dictation into EMR/Billing systems
  • Prepare and assemble medical record documentation/charts for physicians
  • Ensure medical record compliance through self-documentation attestation
  • Update patient history, physical exam, and other pertinent health information in patients' records
  • Prepare and send all documentation to physicians for review and approval via authentication of detailed data entry and facility-specific procedures
  • Monitor basic lab results and screening procedures
  • Comply with hospital and medical facility policies, including HIPAA and Joint Commission regulations
  • Perform clerical duties and tasks to improve provider productivity and clinic workflow as assigned
  • Assign codes to diagnoses and procedures using ICD and CPT codes
  • Ensure codes are accurate and sequenced correctly according to government and insurance regulations
  • Follow up with providers on insufficient or unclear documentation
  • Communicate with clinical staff regarding documentation
  • Search for information in complex or unusual coding cases
  • Review patient charts and documents for accuracy
  • Ensure all codes are current and active

Required Skills and Qualifications:

  • 3-5 years of experience as a Medical Scribe or similar role
  • Administrative writing skills
  • Reporting skills
  • Organizational skills
  • Record-keeping
  • Microsoft Office skills
  • Professionalism, confidentiality, and organization
  • Typing
  • Solid oral and written communication skills
  • Medical coding or certification program completion
  • 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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