
Clinical Documentation Specialist
6 days ago
Our organization is seeking a skilled Medical Scribe to join our team. The ideal candidate will possess excellent administrative writing skills, strong reporting and organizational abilities, as well as proficiency in Microsoft Office.
Job Description:The successful Medical Scribe will be responsible for reviewing physician dictation and transcribing it into clinical notes in electronic medical records (EMRs) and billing systems. They will also prepare and assemble medical record documentation, ensuring compliance with regulatory requirements such as HIPAA and Joint Commission standards.
- Key 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 the patient's chart
- Prepare and send all documentation to physicians for review and approval
- Monitor lab results and screening procedures
- Comply with hospital and medical facility policies, including those relating to confidentiality and data security
- Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned
- Assign codes to diagnoses and procedures using ICD and CPT codes
The ideal candidate will possess the following qualifications:
- 3-5 years of experience as a live 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 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-10 codes and CPT procedures
- Skilled in operating various medical record software and hardware, word-processing, and database software programs
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