Healthcare Documentation Specialist
Há 4 dias
The role of a Medical Scribe involves supporting primary care providers with clinical documentation. Clinical Informatics Specialists assist providers throughout the patient care journey, observing and documenting all patient encounters in real time.
They become experts in value-based care models and the documentation and care of chronic conditions, including ICD-10 and CPT coding.
Scribes use this expertise to help providers identify and close care gaps.
Key Responsibilities:- Patient Encounter Documentation (~80%):
- Observe patient visits alongside providers.
- Create structured notes, including the history of the present illness, assessment, plan, and physical exam.
- Assign relevant CPT and ICD-10 codes.
- Prepare After Visit Summaries.
- Collaborate with providers to ensure accurate and specific documentation.
- Clinical Documentation Improvement (~10%):
- Review medical records and leverage population health tools to support clinical documentation improvement.
- Participate in Daily Huddles and Clinical Documentation Reviews.
- Consult with providers on clinical documentation opportunities.
- Administrative Support (~10%):
- Process orders and referrals.
- Manage tasks and support the care team with additional responsibilities related to clinical documentation.
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Belém, Pará, Brasil GHR Healthcare Tempo inteiro3 days ago Be among the first 25 applicants Get AI-powered advice on this job and more exclusive features. PACU Registered Nurse Jobs – Local Contract Opportunity in Bethlehem, PAAdvance your nursing career as a PACU Registered Nurse with a local contract at an acute care hospital in Bethlehem, Pennsylvania (zip code 18015). This healthcare job is ideal...
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pacu | rn
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