Clinical Documentation Specialist

4 weeks ago

Mumbai, India IKS Health Full time

Position: Clinical Documentation Specialist

Grade:

Reporting To: Team Manager

Department: CARE - Virtual Scribe

Profile Description: This role would be responsible for creating medicolegally compliant, clinically sound, high quality outpatient visit documentation for some of the best US Hospitals across multiple specialties on the electronic platform.

Key Responsibilities:

Process:
Listen and comprehend patient - physician interactions through an audio file
Develop an impression about the clinical condition and plan of action provided by the physician. . The Clinical Document Specialist will not create a Treatment plan, however will have to document the Treatment plan created by the US Physician.
Create and summarize findings and insights into highly structured clinical notes with sections such as - history of present illness, review of systems, physical examination, plan details, PMFSH and similar
Document the summarized findings in the IKS proprietary application and transfer to electronic health records in the client acceptable format as per the account SLA
Maintain the quality of the chart notes as per documentation norms and physician preferences
Understand and maintain desired level of clinical knowledge based on assigned specialty
Work collaboratively with training and quality to improve the provider experience
Share best practices and help create a knowledge repository to capture tacit knowledge
Meet the daily productivity and quality expectations as per set targets.
This job profile involves listening to audio using a headset and typing for a minimum of to hours

People:
Support and be a Buddy to the assigned new Clinical Documentation Specialists on the floor through the buddy program and help the joinees through their first year at IKS.
Support the new joinees in being successful by helping in formulating specialty specific training for the pod/team.
Ensuring that all programs planned for Self Development are completed.
Ensure that Clinical Documentation Specialists get converted to Direct Posters through constant mentoring and coaching.
Responsible for performance of the allocated specialists through constant coaching and feedback and execution of individual development plans.

Client:
Physician edits to be monitored and learning to be shared with the team and TL through the edit analysis report

Qualifications:
Any medical degree MBBS,BHMS, BDS, BUMS,BAMS,BPT is mandatory (All relevant medical degrees)

Role Prerequisites:
Freshers directly out of college/institutions/to the industry OR Minimum to years of experience in the relevant field.
Typing speed of to WPM would be preferred

Functional Competencies:
Good Comprehension Skills and the ability to document clinical information in a grammatically accurate method.
Good Knowledge of Human Anatomy and medical terminologies is a must

Behavioural Competencies:
Accountability
Customer Service Orientation
Communication skills
Team Work
Building & Leveraging Relationships

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