Clinical Documentation Specialist

1 day ago

Nagpur, Maharashtra, India beBeeTranscription Full time US$ 50,000 - US$ 75,000

Medical Transcriptionist Role

We are seeking a skilled Medical Transcriptionist to join our organization. The ideal candidate will have experience using electronic health records (EHRs) and be able to transcribe physician dictation into clinical notes in real-time.

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
  • 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

Requirements

  • 3-5 years of experience as a Live Medical Scribe
  • 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

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