Clinical Documentation Specialist

We are seeking a skilled Clinical Documentation Specialist to join our team. The ideal candidate will have experience using electronic health records (EHRs) and be able to transcribe physician dictation into clinical notes in EMR/Billing systems.

• Review physician dictation and transcribe to clinical notes in EMR/Billing systems, ensuring accuracy and attention to detail.
• Prepare and assemble medical record documentation/charts for physicians, maintaining confidentiality and organization.
• Ensure medical record compliance by self-documentation attestation, adhering to hospital and medical facility policies.
• Update patient history, physical exam, and other pertinent health information in the patient's chart, utilizing knowledge of anatomy, physiology, and medical terminology.
• 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, identifying any discrepancies or issues.
• Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
• Assign codes to diagnoses and procedures, using ICD and CPT codes, ensuring accuracy and adherence to government and insurance regulations.
• Follow up with the provider on any documentation that is insufficient or unclear, resolving issues promptly.
• Communicate with other clinical staff regarding documentation, maintaining effective collaboration and teamwork.
• Search for information in cases where the coding is complex or unusual, employing critical thinking and problem-solving skills.
• Receive and review patient charts and documents for accuracy, verifying the integrity of medical records.
• Review the previous day's batch of patient notes for evaluation and coding, staying current with changing guidelines and regulations.
• Ensure that all codes are current and active, maintaining knowledge of industry developments and advancements.

• 3-5 years of experience as a Live Medical Scriber or similar role.
• Administrative writing skills, including proficiency in formatting and organizing documents.
• Reporting skills, with ability to accurately record and analyze data.
• Organizational skills, with focus on prioritizing tasks and managing multiple projects simultaneously.
• Record-keeping skills, with emphasis on maintaining accurate and confidential medical records.
• Microsoft Office skills, including proficiency in Word, Excel, and other relevant software applications.
• Professionalism, confidentiality, and organization, with commitment to maintaining high standards of professionalism.
• Typing skills, with ability to meet typing requirements and deadlines.
• Solid oral and written communication skills, with ability to effectively interact with healthcare professionals and patients.
• Education, Experience, and Licensing Requirements:
• Medical coding or successful completion of a certification program, such as CPC or CCS.
• Bachelor's degree with pre-health career track preferred, but not required.
• Strong knowledge of anatomy, physiology, and medical terminology, with understanding of industry-standard terminology.
• Familiarity with ICD-X codes and CPT Procedures, with ability to accurately assign codes and maintain knowledge of industry developments.
• Skilled in operating various medical record software and hardware, word-processing, and database software programs.

Our organization offers a dynamic work environment, competitive compensation, and opportunities for growth and professional development. If you are a motivated and detail-oriented individual who is passionate about delivering high-quality clinical documentation, we encourage you to apply for this exciting opportunity.