Clinical Documentation Specialist

JOB DESCRIPTION :

1. Applying knowledge of medical terminology and procedures to evaluate clinical documents.

2. Collecting medical information from healthcare providers and updating medical records.

3. Verifying the accuracy of patient medical information and obtaining missing information.

4. Monitoring diagnoses, treatments, and follow-up entries in medical records.

5. Interpreting and preparing clinical reports for healthcare professionals and public health officials.

6. Ensuring that the content and storage of medical documents comply with federal laws.

7. Keeping abreast of advancements in the field of clinical documentation and changes in regulations.

8. Keeping updated to official coding guidelines for diagnosis and be able to follow the facility specific guidelines and instructions.

9. Maintains confidentiality of patient records at all times.

10. Observes HIPAA compliance.

11. Perform as a team player.

12. Other tasks / functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business.