
Clinical Documentation Specialist
6 hours ago
We are seeking a detail-oriented and organized Clinical Documentation Specialist to join our team. As a key member of our healthcare team, you will play a vital role in ensuring accurate and detailed patient records.
Your primary responsibility will be to document clinical interactions in real-time, working closely with healthcare providers to capture patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions. You will also be responsible for updating and maintaining charts, medication lists, allergies, and problem lists.
Key Responsibilities:- Documenting real-time patient encounters during virtual or recorded consultations using Electronic Medical Records (EMRs)
- Accurately capturing patient data, including medical histories, physical exam findings, and treatment plans
- Maintaining accurate and up-to-date patient records
- Collaborating with healthcare providers to ensure accuracy and completeness of documentation
- Excellent written communication skills
- 1–2 years of experience in a clinical documentation role or as a medical scribe
- Familiarity with medical terminologies and clinical workflows
- A healthcare-related degree is highly preferred
- Proficient in electronic medical record systems
- HIPAA certification is a plus
- Fast and accurate typing skills
- Strong attention to detail and organizational skills
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