
Clinical Records Coordinator
3 days ago
Job Description:
We are seeking a detail-oriented Medical Documentation Specialist to join our team. As a key member of our healthcare services, you will be responsible for reviewing and transcribing physician dictation, preparing medical records, and ensuring compliance with regulatory standards.
Responsibilities:
- Review and transcribe physician dictation into clinical notes in EMR/Billing systems
- Prepare and assemble medical record documentation/charts for physicians
- Ensure medical record compliance by 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 via authentication of detailed data entry and facility-specific procedures
- Monitor the duration of basic lab results and screening procedures
- Comply with hospital and medical facility policies, including those relating to HIPAA and Joint Commission
- Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned
- Assign codes to diagnoses and procedures, using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes
- Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations
- Follow up with the provider on any documentation that is insufficient or unclear
- Communicate with other clinical staff regarding documentation
- Search for information in cases where the coding is complex or unusual
- Receive and review patient charts and documents for accuracy
- Review the previous day's batch of patient notes for evaluation and coding
- Ensure that all codes are current and active
Required Skills and Qualifications:
- 3-5 years of experience as a Live Medical Scriber
- 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-X codes and CPT Procedures
- Skilled in operating various medical record software and hardware, word-processing, and database software programs
Benefits:
- Competitive salary
- Opportunities for professional growth and development
- A supportive and collaborative work environment
Others:
We offer a dynamic and fast-paced work environment, with opportunities for professional growth and development. If you are a motivated and detail-oriented individual with excellent communication skills, we encourage you to apply for this exciting opportunity.
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