Clinical Documentation Specialist

1 week ago


Houston, Texas, United States Plaza OBGYN Full time
About Plaza OB/GYN

We are a reputable medical facility dedicated to providing exceptional healthcare services. As a Clinical Documentation Specialist, you will play a vital role in our clinical team.

Estimated Salary: $45,000 - $60,000 per yearJob Description:

Job Summary: We are seeking an experienced Medical Assistant with Scribe expertise to join our team as a Clinical Documentation Specialist. The successful candidate will be responsible for preparing medical records, assisting physicians during patient visits, and maintaining accurate documentation.

Key Responsibilities:

  • Document Preparation: Prepare medical record documentation and charts for physician review and approval.
  • Transcription Services: Enter patient room with the physician to assist with transcription of medical record documentation using electronic medical record applications.
  • Administrative Support: Assist physician as needed with procedures and exams, update patient history, physical exam, and other pertinent health information in the patient's chart.
  • Clerical Duties: Prepare all documentation for physician review, review lab results and screening tests results, and comply with medical facility policies, including HIPAA regulations.

Additional Responsibilities:

  • Prescription Management: Send prescriptions as needed.
  • Patient Communication: Return patient calls.
  • Laboratory Orders: Write orders for labs, surgeries, and imaging as required.

Qualifications and Skills:

  • Medical Assisting Certification: Possess current certification in Medical Assisting.
  • Administrative Writing: Demonstrate strong administrative writing skills.
  • Medical Terminology: Have knowledge of medical terminology and human anatomy.
  • Software Proficiency: Be skilled in operating various medical record software systems.

Education and Experience:

  • Medical Assisting Training: Possess a minimum of 60 words per minute typing speed.
  • Nursing Career Track: Hold a Bachelor's degree in nursing or a related field (preferred).

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