Clinical Documentation Specialist
23 hours ago
The role of a clinical documentation specialist involves working closely with healthcare providers to document clinical interactions in real-time, ensuring accurate and detailed patient records. This 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) such as Epic, AthenaNet/AthenaHealth, Cerner, or NextGen.
- 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.
- Proficiency 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.
- Computer Processor: Intel Core i5-5000 (5th Gen or higher) or AMD Ryzen 5 or higher.
- Computer Memory/RAM: 8.00 GB.
- Computer Operating System: At least Windows 10/11 64-bit or macOS Ventura.
- Headset: Any USB-type headset with noise-cancelling feature.
- Camera: Capable of a clear and crisp video output.
- A challenging and rewarding career opportunity.
- Competitive compensation package.
- Ongoing training and professional development.
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