Clinical Documentation Specialist
9 hours ago
At the heart of every successful healthcare organization lies accurate and detailed patient records. As a Clinical Documentation Specialist, you will play a vital role in ensuring that our healthcare providers have the time to focus on what matters most – delivering exceptional patient care.
Responsibilities:- Document real-time patient encounters during virtual or recorded consultations using Electronic Medical Records (EMRs) such as Epic, AthenaNet/AthenaHealth, Cerner, or NextGen.
- Accurately capture patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- Update and maintain charts, medication lists, allergies, and problem lists.
- Assist with administrative tasks such as templating notes and handling visit summaries.
- Review prior records to provide context for current visits.
- Maintain communication with providers for clarification and accuracy of documentation.
- Ensure all documentation is HIPAA-compliant and meets clinical and legal standards.
- Must have excellent verbal and written English communication skills.
- At least 1-2 years of experience as a medical scribe or in a clinical documentation role.
- Familiar 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.
- Fast and accurate typing skills.
- Strong attention to detail.
- Organized and highly focused.
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