Clinical Documentation Specialist
18 hours ago
A clinical documentation specialist plays a vital role in the healthcare industry, working closely with medical professionals to document patient interactions in real-time. This ensures accurate and detailed records that support high-quality patient care.
Key Responsibilities:
- 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
- Updating and maintaining 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
- Demonstrating strong attention to detail and discretion in handling sensitive patient data
Qualifications:
- Excellent verbal and written English communication skills
- At least 1–2 years of experience in a clinical documentation role
- Familiarity with medical terminologies and clinical workflows
- A healthcare-related degree is highly preferred
- Proficiency with 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
- Open to working night shifts
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