
Clinical Data Coordinator
10 hours ago
A medical documentation specialist plays a vital role in healthcare by documenting clinical interactions accurately and efficiently, enabling healthcare providers to focus on patient care.
The primary responsibility of a medical documentation specialist is to document real-time patient encounters using electronic medical records (EMRs) such as Epic, AthenaNet/AthenaHealth, Cerner, or NextGen. This involves capturing accurate and detailed patient information, including histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
Key Responsibilities:
- Document patient encounters in EMRs with accuracy and efficiency.
- Capture comprehensive patient information, including medical histories, exam findings, and treatment plans.
- Update and maintain patient charts, medication lists, allergies, and problem lists.
- Assist with administrative tasks, such as note templating and visit summaries.
- Review prior records to provide context for current visits.
- Maintain communication with healthcare providers for clarification and accuracy of documentation.
- Ensure all documentation meets HIPAA standards and clinical requirements.
- Demonstrate strong attention to detail and discretion when handling sensitive patient data.
Requirements:
- 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.
- Open to working flexible shifts.
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