Medical Documentation Collector

4 weeks ago


Queens County, United States The Bachrach Group Full time $20 - $21
Job DescriptionJob Description

Key Responsibilities:

  1. Document Collection & Review:

    • Collect, organize, and manage patient clinical documentation from various sources including electronic health records (EHR), paper charts, and physician notes.
    • Ensure all relevant documentation is obtained and accurately reflects the patient’s medical history, diagnoses, and treatment.
  2. Quality Assurance:

    • Review clinical documentation for accuracy, completeness, and consistency.
    • Identify and flag discrepancies or incomplete documentation for further review by the CDI team or healthcare providers.
  3. Collaboration:

    • Work closely with physicians, nurses, and other healthcare providers to clarify and obtain additional documentation as needed.
    • Collaborate with the coding team to ensure documentation supports appropriate coding and billing practices.
  4. Compliance & Standards:

    • Ensure clinical documentation adheres to regulatory requirements, industry standards, and organizational policies.
    • Stay updated on changes in healthcare regulations and documentation requirements.
  5. Data Entry & Management:

    • Accurately enter and update patient information in the electronic health records (EHR) system.
    • Maintain organized and secure records of all collected documentation.
  6. Reporting:

    • Generate reports on documentation quality, completeness, and areas requiring improvement.
    • Assist in preparing documentation for audits or reviews by regulatory agencies.
  7. Continuous Improvement:

    • Participate in ongoing training and professional development to stay current with best practices in clinical documentation.
    • Contribute to the development and implementation of documentation improvement initiatives within the organization.

Qualifications:

  • Education: High school diploma or equivalent required; Associate’s or Bachelor’s degree in Health Information Management, Nursing, or a related field preferred.
  • Experience: Previous experience in clinical documentation, health information management, or a related healthcare field is preferred.
  • Certifications: Certified Clinical Documentation Specialist (CCDS) or similar certification is a plus.
  • Technical Skills: Proficiency in using electronic health records (EHR) systems and Microsoft Office Suite. Strong typing and data entry skills.

 

Company DescriptionThe Bachrach Group LTD. (TBG) has been building better workforces with extraordinary talent based on specific functional experience, one position at a time, for nearly 50 years. Our commitment to sourcing top-notch talent has made us national leaders in both staffing and executive search.Company DescriptionThe Bachrach Group LTD. (TBG) has been building better workforces with extraordinary talent based on specific functional experience, one position at a time, for nearly 50 years. Our commitment to sourcing top-notch talent has made us national leaders in both staffing and executive search.

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