Clinical Documentation Specialist
13 hours ago
Clinical Documentation Specialist
About the Role
This position is designed to support clinicians by freeing them from documentation responsibilities. By providing real-time scribing and accurate electronic health record entries, the Clinical Documentation Specialist ensures that records are complete, compliant, and ready for billing.
The Impact You Will Make
- You will accurately document patient encounters directly into the electronic health record during or immediately after visits.
- You will capture relevant history, objective findings, assessments, treatment plans, and outcomes in clear, structured notes.
- You will use clinic templates and standards to ensure that notes are billable, compliant, and ready for provider sign-off.
Responsibilities
- You will prepare and edit patient notes, visit summaries, progress reports, and letters to referring physicians.
- You will maintain consistency of records across encounters and ensure timely chart updates.
- You will organize and track outstanding documentation for provider review.
Requirements
- You must have proven experience as a medical scribe, medical virtual assistant, or healthcare documentation specialist.
- You must possess strong written and spoken English communication skills.
- You must have a typing speed of at least 45 words per minute with high accuracy.
- You must have working knowledge of basic medical terminology (healthcare/clinical context).
- You must be proficient with electronic health record documentation and Microsoft Office (Word, Excel, Outlook), with strict adherence to HIPAA.
Skills
- You must be proficient with electronic health record data entry and workflow navigation.
- You must have strong Microsoft Office skills (Word, Excel, Outlook).
- You must have excellent attention to detail, organization, and time management.
- You must have confident, professional communication with clinicians and staff.
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