Clinical Documentation Specialist
13 hours ago
A medical scribe plays a vital role in the healthcare industry, working closely with healthcare providers to document clinical interactions in real-time.
This position allows medical professionals to focus more on patient care by handling the documentation side of the encounter, enabling them to deliver high-quality care and build strong relationships with patients.
Responsibilities:- Documenting patient encounters during virtual or recorded consultations using electronic medical records (EMRs).
- Capturing accurate and detailed patient information, including histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- Updating and maintaining charts, medication lists, allergies, and problem lists, ensuring that all documentation is up-to-date and easily accessible.
- Assisting with administrative tasks such as templating notes and handling visit summaries, streamlining the workflow and improving productivity.
- Reviewing prior records to provide context for current visits, enhancing the overall quality of care and reducing errors.
- Maintaining effective communication with healthcare providers for clarification and accuracy of documentation, fostering collaboration and teamwork.
- Ensuring that all documentation is HIPAA-compliant and meets clinical and legal standards, safeguarding sensitive patient information and maintaining confidentiality.
- Excellent verbal and written English communication skills, with the ability to articulate complex ideas and concepts clearly and concisely.
- At least 1–2 years of experience as a medical scribe or in a clinical documentation role, demonstrating a strong understanding of medical terminology and clinical workflows.
- Familiarity with medical terminologies and clinical workflows, with the ability to apply this knowledge in a fast-paced environment.
- A healthcare-related degree is highly preferred, but not required, as long as the candidate has relevant work experience and training.
- Proficiency in Google Workspace and/or Microsoft Office, with the ability to adapt to new software and systems quickly.
- Experience with EMRs such as Epic, Cerner, or AthenaHealth is a plus, but not necessary, as long as the candidate has a willingness to learn and adapt.
- HIPAA Certification is a plus, but not required, as long as the candidate has demonstrated a strong understanding of HIPAA regulations and compliance.
- Fast and accurate typing skills, with the ability to maintain a high level of productivity and accuracy in a fast-paced environment.
- Strong attention to detail, with the ability to catch errors and inconsistencies in documentation, and correct them promptly.
- Organized and highly focused, with the ability to prioritize tasks and manage multiple responsibilities effectively.
- Starting rate: $800 monthly.
- Independent contractor employment type, offering flexibility and autonomy in your work schedule.
- Free training and development opportunities, enabling you to enhance your skills and advance your career.
- Paid time off, allowing you to recharge and take breaks when needed.
- HMO coverage, providing comprehensive health insurance and protecting your well-being.
- Optical rewards, offering incentives and recognition for your hard work and dedication.
- Performance-based increase, enabling you to earn higher pay rates based on your performance and achievements.
- Permanent work-from-home arrangement, offering flexibility and convenience in your work arrangements.
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