Clinical Documentation Specialist

11 hours ago

Rajkot, Gujarat, India beBeeClinical Full time ₹ 8,00,000 - ₹ 12,00,000
Medical Scribe Role

We are seeking an experienced Medical Scribe to join our team in a dynamic and fast-paced environment. The ideal candidate will possess 3-5 years of experience as a Live Medical Scribe, with expertise in administrative writing, reporting, and organizational skills. Strong Microsoft Office skills and proficiency in operating medical record software are essential.

Key Responsibilities:
  • Reviews physician dictation and transcribes to clinical notes in EMR/Billing systems.
  • Prepares and assembles medical record documentation/charts for physicians.
  • Ensures medical record compliance by self-documentation attestation.
  • Updates patient history, physical exam, and other pertinent health information in the patient's chart.
  • Prepares and sends all documentation to physicians for review and approval via authentication of detailed data entry and facility-specific procedures.
  • Monitors the duration of basic lab results and screening procedures.
  • Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
  • Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
  • Assigns codes to diagnoses and procedures using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes.
  • Evaluates coding accuracy and sequences codes correctly in accordance with government and insurance regulations.

The successful candidate will have a Bachelor's degree with a pre-health career track preferred, and strong knowledge of anatomy, physiology, and medical terminology. Familiarity with ICD-X codes and CPT Procedures is also essential.

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