Clinical Documentation Specialist
3 weeks ago
Job Summary:
">We are seeking a highly skilled Clinical Documentation Specialist to join our team at Ladgov Corporation. In this role, you will be responsible for preparing and assembling medical record documentation/charts for physicians. You will also enter the patient room with the physician during patient visits to capture and transcribe medical record documentation utilizing electronic medical record applications.
Duties and Responsibilities:
">- Prepare and assemble medical record documentation/charts for physicians.
- Enter the patient room with the physician during patient visits to capture and transcribe medical record documentation utilizing electronic medical record applications.
- Ensure medical record compliance by self-documentation attestation.
- Accurately and thoroughly document medical visits and procedures as they are being performed by the physician.
- Print and code patient education and explanations of risks and benefits.
- Prepare referral letters as directed by the physician.
- Prepare and send all documentation to the physician for review and approval.
- Spot mistakes or inconsistencies in medical documentation and correct the information to reduce errors.
- Maintain a clean and professional working environment.
- Accurately enter new patient information into electronic medical records.
- Enter orders into the electronic medical record system.
- Create and update exam templates in the EMR for the physician.
- Comply with hospital/clinic and ProScribe policies, including those relating to HIPAA and Joint Commission.
- Regular and reliable attendance at assigned facilities is required.
Requirements:
">- High school diploma or equivalent.
- A minimum of three years of providing medical scribe services.
- Ability to demonstrate knowledge of medical terminology and human anatomy.
- Skilled in operating various medical record software and hardware, word-processing, and database software programs.
- Strong written and verbal communication skills.
- Strong work ethic and attention to detail in a fast-paced work environment.
Estimated Salary: $45,000 - $60,000 per year, depending on experience.
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