
Clinical Documentation Specialist
5 hours ago
A healthcare documentation specialist plays a vital role in the medical industry, working closely with healthcare professionals to document clinical interactions in real-time. This position enables medical professionals to focus on patient care by handling the documentation side of the encounter.
This role requires attention to detail and strong communication skills to accurately capture patient information.
The specialist will be responsible for:
- Documenting patient encounters during virtual or recorded consultations using Electronic Medical Records (EMRs).
- Capturing patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- Maintaining accurate and up-to-date charts, medication lists, allergies, and problem lists.
- Assisting with administrative tasks such as templating notes and handling visit summaries.
- Reviewing prior records to provide context for current visits.
- Maintaining communication with providers for clarification and accuracy of documentation.
- Ensuring all documentation is HIPAA-compliant and meets clinical and legal standards.
To succeed in this role, you should possess:
Key Requirements- Excellent verbal and written English communication skills.
- At least 1–2 years of experience as a medical scribe or in a clinical documentation role.
- Familiarity with medical terminologies and clinical workflows.
- A healthcare-related degree is highly preferred.
- Proficiency in Google Workspace and/or Microsoft Office.
- Experience with EMRs such as Epic, Cerner, or AthenaHealth is a plus.
- HIPAA Certification is a plus.
- Fast and accurate typing skills.
- Strong attention to detail.
- Organized and highly focused.
We offer a dynamic work environment that values precision and dedication. If you are passionate about delivering exceptional results and contributing to the success of our organization, we encourage you to apply for this exciting opportunity.
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