Chief Clinical Documentarian

4 days ago

Nellore, Andhra Pradesh, India beBeeDocumentation Full time ₹ 7,00,000 - ₹ 13,18,000
Medical Documentation Specialist

The Medical Documentation Specialist plays a vital role in ensuring the accuracy and efficiency of medical documentation. This individual will be responsible for reviewing physician dictation, transcribing it into clinical notes, and updating patient information in the electronic health record (EHR).

Key responsibilities include:

  • Reviewing physician dictation and transcribing to clinical notes in EMR/Billing systems.
  • Preparing and assembling medical record documentation/charts for physicians.
  • Ensuring medical record compliance by self-documentation attestation.
  • Updating patient history, physical exam, and other pertinent health information in the patient's EHR.
  • Preparing and sending all documentation to physicians for review and approval via authentication of detailed data entry and facility-specific procedures.
  • Monitoring the duration of basic lab results and screening procedures.
  • Complying with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
  • Performing other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
  • Assigning codes to diagnoses and procedures using ICD and CPT codes.
  • Ensuring accurate and sequenced coding in accordance with government and insurance regulations.
Required Skills and Qualifications

For this position, we are seeking an individual with the following skills and qualifications:

  • 3-5 years of experience as a live medical scribe or similar medical documentation specialist role.
  • 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

Applicants must have:

  • 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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