
Clinical Documentation Professional
9 hours ago
We are seeking a highly skilled Medical Documentation Specialist to join our team. As a Medical Documentation Specialist, you will work closely with healthcare providers to document clinical interactions in real time, ensuring accurate and detailed patient records.
Key Responsibilities- Documenting real-time patient encounters during virtual or recorded consultations using Electronic Medical Records (EMRs)
- Accurately 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
- 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
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