Clinical Documentation Specialist

2 weeks ago

Allahabad, Uttar Pradesh, India beBeeClinical Full time ₹ 15,00,000 - ₹ 25,00,000
Job Overview:

As a Medical Scribe Manager, you will play a vital role in supporting healthcare providers by leveraging new technologies to save time and money.

The ideal candidate has experience using Electronic Health Records (EHR) systems to transcribe visitation notes into patient charts while understanding the nuances between multiple providers in real-time.

Key Responsibilities:
  • Medical Record Management: Review and transcribe physician dictation into clinical notes in EMR/Billing systems.
  • Documentation Preparation: Prepare and assemble medical record documentation/charts for physicians.
  • Compliance Ensurance: Ensure medical record compliance through self-documentation attestation.
  • Patient History Updates: Update patient history, physical exam, and other pertinent health information in the patient's chart.
  • Document Distribution: Prepare and send all documentation to physicians for review and approval via authentication of detailed data entry and facility-specific procedures.
  • Lab Result Monitoring: Monitor basic lab results and screening procedures duration.
  • Regulatory Compliance: Comply with hospital and medical facility policies, including HIPAA and Joint Commission regulations.
  • Clerical Support: Perform clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
  • Coding Assignments: Assign codes to diagnoses and procedures using ICD and CPT codes.
  • Coding Accuracy: Ensure accurate and sequenced coding in accordance with government and insurance regulations.
  • Provider Follow-up: Follow up with providers on insufficient or unclear documentation.
Requirements:
  • Experience: 3-5 years of experience as a Live Medical Scriber.
  • Writing Skills: Administrative writing skills.
  • Reporting Skills: Reporting skills.
  • Organizational Skills: Organizational skills.
  • Record-keeping: Record-keeping.
  • Microsoft Office: Microsoft Office skills.
  • Professionalism: Professionalism, confidentiality, and organization.
  • Typing: Typing.
  • Communication: Solid oral and written communication skills.
  • Education: Bachelor's degree with pre-health career track preferred.
  • Knowledge: Strong knowledge of anatomy, physiology, and medical terminology.
  • Licensing: Medical coding or successful completion of a certification program.

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