Clinical Documentation Professional
11 hours ago
A medical documentation specialist plays a vital role in the healthcare industry by accurately documenting clinical interactions in real-time. This enables medical professionals to focus on patient care while handling the documentation side of the encounter.
This critical support function requires attention to detail, effective communication skills, and knowledge of medical terminologies and clinical workflows. The ideal candidate will have experience as a medical scribe or in a similar clinical documentation role.
Key Responsibilities:- Documentation: Accurately document patient encounters, histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions using Electronic Medical Records (EMRs).
- Chart Maintenance: Update and maintain charts, medication lists, allergies, and problem lists.
- Administrative Tasks: Assist with administrative tasks such as templating notes and handling visit summaries.
- Communication: Maintain open communication with providers for clarification and accuracy of documentation.
- Verbal and Written Communication: Excellent English communication skills.
- Clinical Experience: At least 1–2 years of experience as a medical scribe or in a clinical documentation role.
- Maintenance Knowledge: Familiarity with medical terminologies and clinical workflows.
- Education: A healthcare-related degree is highly preferred.
- Technical Skills: Proficient with Google Workspace and/or Microsoft Office.
- Specialized Training: Experience with EMRs such as Epic, Cerner, or AthenaHealth is a plus.
- Certification: HIPAA Certification is a plus.
- Typing Speed: Fast and accurate typing skills.
- Attention to Detail: Strong attention to detail.
- Organizational Skills: Organized and highly focused.
- Availability: Open to working night shifts.
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