Job Summary
We are seeking a detail-oriented and efficient Medical Documentation Specialist to join our healthcare team. The ideal candidate will be responsible for accurately documenting patient information, including history, physical exams, assessments, and treatment plans during patient visits. This role requires proficiency in navigating Electronic Health Record (EHR) systems, maintaining patient confidentiality, and collaborating closely with physicians and medical staff to ensure precise and timely medical documentation.
Key Responsibilities
- Accurately document patient history, physical examinations, clinical assessments, and treatment plans during each patient encounter.
- Record laboratory and imaging results, medical procedures performed, and any follow-up instructions provided to patients.
- Efficiently navigate and utilize the Electronic Health Record (EHR) system to input, update, and retrieve patient information as needed.
- Maintain strict confidentiality and security of all patient data, adhering to HIPAA regulations and organizational policies.
- Communicate effectively with physicians and other medical staff to clarify documentation requirements and resolve any discrepancies.
- Review and proofread medical notes to ensure both grammatical correctness and clinical accuracy before final submission.
- Ensure all medical charts and documentation are completed and submitted in a timely manner to support patient care continuity and compliance.
Required Qualifications
- Excellent written and verbal communication skills, enabling clear and professional interaction with healthcare providers and team members.
- Strong attention to detail with the ability to multitask and manage competing priorities in a fast-paced clinical environment.
- Solid understanding of medical terminology, clinical workflows, and healthcare documentation standards.
- Proven ability to work efficiently under pressure and adapt to changing priorities and processes.
Preferred Qualifications and Benefits
- Familiarity with widely used EHR systems such as Epic, Cerner, or Athena is highly advantageous and will support smoother integration into our documentation processes.
This position offers the opportunity to contribute to high-quality patient care by ensuring accurate and comprehensive medical documentation. If you are meticulous, communicative, and comfortable working in a dynamic healthcare setting, we encourage you to apply.