
Clinical Documentation Specialist
9 hours ago
Job Title: Clinical Documentation Specialist
Job Description:A clinical documentation specialist works closely with healthcare providers to document clinical interactions in real time, ensuring accurate and detailed patient records. This role allows medical professionals to focus more on patient care by handling the documentation side of the encounter.
- 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
- 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
- Starting rate $800 (USD) monthly
- Employment type: Independent Contractor
- Free Training
- Paid Time Offs
- HMO Coverage
- Optical Rewards
- Performance-Based Increase
- Permanent Work From Home
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