
Clinical Documentation Specialist
2 weeks ago
As a Medical Documenter, you will play a pivotal role in streamlining clinical documentation processes for healthcare providers.
- Reviews physician dictation and transcribes to accurate clinical notes in EMR/Billing systems
- Prepares and assembles medical record documentation/charts for physicians with precision.
- Ensures medical record compliance by self-documentation attestation, maintaining the highest standards of data integrity.
- Updates patient history, physical exam, and other pertinent health information in the patient's chart with utmost care.
Key Responsibilities:
- Monitors lab results and screening procedures, ensuring timely interventions when necessary.
- Assigns codes to diagnoses and procedures using ICD and CPT codes with attention to detail.
- Follows up with providers on incomplete or unclear documentation, facilitating seamless communication.
- Communicates effectively with clinical staff regarding documentation, promoting a culture of transparency.
- Conducts thorough searches for information in complex cases, delivering actionable insights.
Requirements:
- 3-5 years of experience as a Live Medical Scribe or equivalent position
- Exceptional administrative writing skills, capable of producing clear and concise reports.
- Strong reporting skills, with the ability to analyze data and present findings effectively.
- Excellent organizational skills, with the capacity to prioritize tasks and manage multiple projects simultaneously.
- Proficiency in record-keeping, with a keen eye for detail and a commitment to accuracy.
- Advanced Microsoft Office skills, with expertise in software applications relevant to the role.
Preferred Qualifications:
- Completion of a medical coding certification program or equivalent training
- Bachelor's degree in a pre-health career track or related field
- In-depth knowledge of anatomy, physiology, and medical terminology, with a passion for staying up-to-date on industry developments.
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