Healthcare Documentation Specialist

4 days ago

Rajahmundry, Andhra Pradesh, India beBeeScribing Full time ₹ 60,00,000 - ₹ 80,00,000

Medical Scribe Leader

A medical scribe leader is a key member of the healthcare team. They play a vital role in optimizing provider productivity and improving clinic workflow by using advanced technologies to manage patient information efficiently.

Job Responsibilities:

  • Documentation Management: Reviews physician dictation and transcribes it into clinical notes, ensuring accuracy and completeness in electronic health records (EHRs).
  • Record Preparation: Assembles medical record documentation/charts for physicians, maintaining compliance with regulatory requirements.
  • Quality Control: Ensures medical record accuracy through self-documentation attestation and updates patient history, physical exam, and other relevant health information.
  • Documentation Review: Prepares and sends all documentation to physicians for review and approval, utilizing detailed data entry and facility-specific procedures.
  • Lab Results Monitoring: Tracks basic lab results and screening procedures, adhering to hospital and medical facility policies.
  • Clerical Duties: Performs various clerical tasks to enhance provider efficiency and clinic workflow as assigned.
  • Coding and Compliance: Assigns codes to diagnoses and procedures, using ICD and CPT codes, ensuring accuracy and adherence to government and insurance regulations.
  • Communication: Follows up with providers on incomplete or unclear documentation and communicates with clinical staff regarding documentation accuracy.

Requirements:

  • 3-5 years of experience as a live medical scribe.
  • Administrative writing skills.
  • Reporting skills.
  • Organizational skills.
  • Record-keeping skills.
  • Microsoft Office proficiency.
  • Professionalism, confidentiality, and organization.
  • Typing speed and accuracy.
  • Solid oral and written communication skills.
  • Education and Experience:
  • Medical Coding or Certification: Medical coding certification or successful completion of a certification program.
  • Degree Preference: Bachelor's degree with a pre-health career track preferred.
  • Medical Knowledge: Strong knowledge of anatomy, physiology, and medical terminology.
  • Coding Familiarity: Familiarity with ICD-X codes and CPT Procedures.
  • Software Proficiency: Skilled in operating various medical record software and hardware, word-processing, and database software programs.

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