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Clinical Documentation Specialist
1 month ago
Job Summary
Orlando Health Medical Group is a comprehensive physician group serving patients from across the southeastern United States. With more than 200 practices and 1,200 physicians, the group has a strong representation in over 55 specialties, including cardiology, vascular medicine, orthopedics, oncology, digestive health, neurology, neurosurgery, bariatric surgery, general surgery, bone marrow transplant, and critical care medicine, as well as more than 30 pediatric subspecialties, women's health, primary care, and the largest hospitalist program in Florida.
The Clinical Documentation Specialist is trained in structured clinical assessments, professional documentation, and team-based care in an ambulatory setting to prepare and assemble medical record documentation for providers to facilitate efficient and effective medical care between patients and clinical team members.
Key Responsibilities
Gather data through patient or caregiver interviews and direct or indirect observation of clinical team members.
Document clinical data, assessments, procedures, and patient education according to Orlando Health and department-specific policies.
Accurately and thoroughly document medical visits and procedures as they are being performed by the physician or APP.
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.
Update patient history, physical exam, and other pertinent health information in the patient.
Prepare and send all documentation to physicians for review and approval via authentication of detailed data entry and facility-specific procedures.
Monitor the duration of basic lab results and screening procedures.
Comply with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
Support and demonstrate effective and professional communication with patients and family members.
Adhere to and assure compliance with Orlando Health and department-specific policy, procedures, value statements, and Commitment to Excellence standards.
Consistently demonstrate personal and patient safety practices and adherence to infection control standards outlined in Orlando Health policies.
Maintain reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA, and other federal, state, and local standards.
Qualifications
High school graduate or equivalent.
Successful completion of an Orlando Health clinical documentation training program or Scribe training program within 60 days of hire.
One (1) year of experience in a healthcare-related position or health-related education.
Skilled in operating various medical record software and hardware, word-processing, and database software programs.
