Clinical Documentation Specilist

3 days ago

Madhapur Hyderabad Telangana, India TechnoComp computer services pvt ltd Full time

Clinical Documentation Reviewer:
The **Clinical Documentation Review** and **Clinical Documentation Specialist** is a onsite position responsible for ensuring the accuracy and completeness of provider documentation in electronic health records. This role involves interpreting clinical information and communicating with physicians to resolve conflicting, incomplete, or inconsistent documentation.

Key Responsibilities
- Review In-patient records to ensure clinical documentation is accurate and supports the assigned severity of illness and risk of mortality.
- Formulate and issue compliant queries to physicians for documentation that needs clarification.
- Maintain strong collaborative relationships with physicians and other team members.
- Document all reviews and query follow-up in a timely manner.
- Stay proficient with current and new technologies used in the role.

Educational Background
- **Bachelor's degree** is required **MBBS, B.Sc or M.Sc Nurshing, Phisicians or related to patient care experience**.
- **3+ years of experience** in an acute care facility is required.
- Must be a **Registered Professional Nurse or Doctors** with a current license in the state of residence.

Required Skills & Abilities
- **Clinical Judgement**: Ability to use critical thinking and independent discretion to determine when a physician query is necessary.
- **Communication**: Excellent interpersonal skills to effectively engage and collaborate with physicians and colleagues.
- **Technical Proficiency**: Ability to use multiple electronic health record technologies simultaneously.
- **Attention to Detail**: Meticulous approach to reviewing and documenting information.
- **Problem-Solving**: Proactive in resolving issues and achieving desired results.

Physical Demands & Travel
- This is a **onsite position** willing to work in **US shift** 2- Cab, Dinner and all benefits.
- The role involves a significant amount of **sitting, typing, and using a computer** for extended periods.

Pay: From ₹500,000.00 per year

**Benefits**:

- Food provided
- Health insurance
- Life insurance
- Paid time off
- Provident Fund

**Education**:

- Bachelor's (required)

**Experience**:

- Patient care, ICU or critical care: 2 years (required)
- Clinical documentation: 2 years (required)

License/Certification:

- Doctor or Nurse in clinical experience (required)

**Location**:

- Madhapur, Hyderabad, Telangana (required)

Shift availability:

- Night Shift (required)

Work Location: In person

Expected Start Date: 13/08/2025

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