
Clinical Documentation Professional
4 hours ago
A Medical Documentation Specialist plays a pivotal role in the healthcare industry by accurately recording clinical interactions in real-time. This enables medical professionals to focus on patient care while ensuring precise and detailed patient records.
This key function is crucial for the success of any healthcare organization, as it directly impacts the quality of care provided to patients. By maintaining accurate and up-to-date patient records, medical professionals can make informed decisions about treatment plans and ensure continuity of care.
The responsibilities of a Medical Documentation Specialist include:
- Recording patient encounters in real-time using electronic medical records (EMRs)
- Capturing patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions with high accuracy
- Maintaining charts, medication lists, allergies, and problem lists up-to-date
- 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
- Excellent verbal and written English communication skills
- 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
- Open to working night shifts
As a Medical Documentation Specialist, you will play a vital role in the healthcare team, contributing to the delivery of exceptional patient care. If you possess excellent documentation skills, a passion for healthcare, and a commitment to accuracy and precision, we encourage you to apply for this rewarding opportunity.
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