
Clinical Documentation Specialist
7 days ago
This role is an exceptional opportunity for medical professionals to focus on patient care while handling the documentation side of clinical encounters.
As a Clinical Documentation Specialist, you will work closely with healthcare providers to document accurate and detailed patient records in real-time.
Key Responsibilities:- Documenting patient encounters using Electronic Medical Records (EMRs).
- Capturing patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- 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.
- Proficient with Google Workspace and/or Microsoft Office.
- Experience with EMRs such as Epic, Cerner, or AthenaHealth is a plus.
- HIPAA Certification is a plus.
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