clinical documentation specialist

National Dental Care

We are looking for BDS doctor non clinical role for National Dental care KPHB branch Hyderabad location who can join immediately.Documentation verificationNon clinical roleJob Types: Full-time, PermanentBenefits:<ul><li>Provident Fund</li></ul>Work Location: In person

Clinical Documentation Specialist

Trinity Health

Employment Type: 
Full time
 
Shift: 
Description: 
Utilizes clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness and accuracy of medical record documentation through extensive record review.
 
Our Commitment
 
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Clinical Documentation Specialist Remote

UNC Health

<div>Description
Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.
Summary: 
This positon trains and audits Inpatient and Outpatient Clinical Documentation Specialists (CDS) across all HCS entities that are owned or managed that have opted into shared services. This position reports to the HCS Supervisor Coding and CDI Quality and Training. This position may travel from entity to entity across the state to train and shadow round with Clinical Documentation Specialists. The CDS auditor provides elbow to elbow support during training and education as well as through webex. This position may travel to clinics and work with physicians and CDS on documentation education and issues for optimizing HCCs. 
Responsibilities: 
1. Audits CDS to assure a minimum of 95% accuracy and recommends education and training related to results. 
2. Monitor and provide feedback to new-hire CDS, as they progress through and complete the CDS training modules. 
3. Provides ongoing documentation and coding education to CDI Physician Advisers and CDS staff. 
4. Provides input to the CDS's performance evaluation completed and conducted by the Supervisor. 
5. Participates in the hiring and selection of new CDS with the hiring manager as requested. 
6. Analyzes and audits medical records concurrently to ensure that the clinical information within the medical record is accurate, complete, and compliant. 
7. Educates CDS, physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories and complexity of care rendered to all patients. Educates on proper creation of provider compliant queries. 
8. Ensures compliance with third party and State and Federal regulations. 
9. Audits CDS medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality. Assures accurate assignment of Working MS-DRG, ICD-10-CM/PCS codes and CPT codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations. 
10. Identifies cases for CDI Physician Advisor intervention and coordinates the CDI Physician Advisor scheduling, reviews and educational opportunities with residents, faculty, Advanced Practice Professionals (APP). 
11. Collects the statistics from the reviews and maintains accurate records of review activities to document cost/benefits and ROI. 
12. Assists with overseeing the quarterly CDI Physician Advisor meetings to discuss the status of the program and generates the dashboard reports for review and discussion. 
13. Conducts with the assistance/input of the appropriate CDS, educational sessions for physicians, CDI Physician Advisors, and coding staff as well as the CDS staff.<h3 class="jobSectionHeader"> 
Other Information</h3><div>
Other information: 
Education Requirements: 
<ul><li>Associate's degree in Health Information Management, Nursing or related field.</li><li>Successful completion of the Clinical Documentation Specialist Proficiency Test.</li></ul>
Licensure/Certification Requirements: 
<ul><li>Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification - RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license - Advance Practice Provider (NP or PA) license- Medical Doctor (MD) license with applicable credential</li></ul>
Professional Experience Requirements: 
<ul><li>Three (3) years of CDS experience</li></ul>
Knowledge/Skills/and Abilities Requirements: 
<ul><li>Strong knowledge of ICD-10-CM, ICD-10-PCS, and CPT coding, MS DRG, hierarchical condition categories (HCC), and CDI documentation processes. Ability to interpret federal and state regulations as they relate to coding and compliance. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills. Strong critical thinking and sound judgement in decision making.</li></ul></div><h3 class="jobSectionHeader"> 
Job Details</h3>
Legal Employer: NCHEALTH
Entity: Shared Services 
Organization Unit: HIM Coding &amp; CDI Quality
Work Type: Full Time 
Standard Hours Per Week: 40.00
Salary Range: $35.52 - $51.05 per hour (Hiring Range) 
Pay offers are determined by experience and internal equity 
Work Assignment Type: Remote
Work Schedule: Day Job
Location of Job: US:NC:Chapel Hill
Exempt From Overtime: Exempt: Yes 
This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Health Care System, in a department that provides shared services to operations across UNC Health Care; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job. 
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. 
 
UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.</div>

Clinical Documentation Specialist Auditor - HIM Coding & CDI Quality

SARA INFOTECH

About the RoleWe are looking for a detail-oriented Medical Scribe / Medical Transcriptionist to support US-based physicians and healthcare providers by accurately documenting clinical encounters and transcribing medical reports. This role is ideal for candidates with strong English communication, excellent typing skills, and knowledge of medical terminology, comfortable with working night shifts aligned with US time zones.Key Responsibilities<ul><li>Listen to physician dictations or live doctor-patient interactions and accurately transcribe medical notes into Electronic Health Record (EHR) systems.</li><li>Document patient history, examinations, assessments, procedures, and treatment plans in real time or from audio files.</li><li>Review, edit and proofread transcriptions for accuracy, grammar, and clarity.</li><li>Ensure all medical records are complete, error-free, and compliant with documentation standards.</li><li>Maintain strict patient confidentiality and data security standards. LinkedIn Business Solutions</li><li>Communicate with supervisors or clinicians to clarify unclear dictations and correct discrepancies.</li><li>Manage multiple files, meet turnaround deadlines, and assist with chart preparation tasks.</li></ul>QualificationsRequired:<ul><li>Strong English communication, typing, and listening skills.</li><li>Typing speed: 50&ndash;60+ WPM or higher.</li><li>Knowledge of medical terminology, anatomy, and clinical procedures.</li><li>Comfortable working night shifts to align with US healthcare provider schedules.</li></ul>Preferred:<ul><li>Diploma or certification in Medical Transcription / Medical Scribing.</li><li>Experience with EHR/EMR systems (e.g., Epic, Cerner, Athena).</li><li>Prior experience in medical transcription, scribing, or remote clinical documentation.</li></ul>Skills &amp; Competencies✔ Accurate and fast typing ✔ Excellent command of written and spoken English ✔ Attention to detail &amp; confidentiality ✔ Ability to work independently and multitask ✔ Basic computer proficiency (MS Office/EHR software)Work Environment<ul><li>Hybrid (office or remote) depending on company policy.</li><li>Night shift work aligned with US time zones.</li><li>Supportive team environment with training provided for US clinical documentation.</li></ul>Benefits<ul><li>Competitive salary and performance incentives.</li><li>Training and development opportunities.</li></ul>Job Types: Full-time, PermanentPay: ₹20,000.00 - ₹56,000.00 per monthBenefits:<ul><li>Health insurance</li><li>Provident Fund</li></ul>Work Location: In person

Medical scribe/ Transcriptionist

Methodist Hospitals

<div>Overview:
<div>
Facilitates and obtains appropriate and complete medical record documentation to reflect patient acuity level and care provided. Ensures that clinical documentation is accurately and compliantly captured at the point of service.</div>
Responsibilities:
<div>
PRINCIPAL DUTIES AND RESPONSIBILITIES(*Essential Functions)</div><ul><li>
Responsible for facilitating concurrent documentation of the medical record to achieve accurate inpatient coding and legitimate DRG assignment for billing integrity. Reviews all provider documentation as necessary to ensure complete and accurate documentation. Collaborates with HIM Coders to ensure that the clinical information used in measuring and reporting outcomes is complete and accurate and reimbursement is received fro the level of services rendered to patients with DRG-based payers.</li><li>
Participates in education of members of the patient care team on documentation guidelines as guided by department leadership.</li><li>
Collect and analyze data to provide reports and make recommendations.</li><li>
Completes admission reviews of patient records within 24-48 hours of admission for specified patient population to evaluate documentation and generate the working DRG.</li><li>
Conducts concurrent follow-up reviews of records as necessary, not to exceed 4 days from prior review. Update notes and revise working DRG based on new documentation.</li><li>
Electronically query physicians/other providers regarding missing, unclear, or conflicting medical record documentation and obtains additional documentation within the medical record when needed.</li><li>
Document all reviews in the CDI application to facilitate tracking, data collection, and communication with coders and department leaders.</li><li>
Take all necessary action to resolve physician queries prior to patient discharge.</li><li>
Contribute to and participate in physician, nursing, and other ancillary staff education documentation requirements.</li><li>
Utilize EHR Clinical Documentation Improvement process flow tools to collect data to support reporting of required indicators - Number of reviews per day/patient - Query generation - Query completion to include outcome - Current and expected DRG with weight change - APR-DRG SOI score improvement.</li><li>
Make recommendations for change processes required to capture needed documentation, such as note template and query content redesign.</li></ul>
Qualifications:
<div>
JOB SPECIFICATIONS(Minimum Requirements) 
 
KNOWLEDGE, SKILLS, AND ABILITIES</div><ul><li>
Registered Health Information Technologist/Registered Health Information Administrator</li><li>
Excellent communication skills</li><li>
Ability to work independently and in a team environment.</li><li>
Self-starter, professional courtesy, positive attitude.</li><li>
Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality, and integrity of employee, patient and family, organizational, or other medical information. Understands and supports the commitment of Methodist Hospitals in adhering to federal, state, and local laws, rules, and regulations governing ethical business practices for healthcare providers.</li></ul><div> 
EDUCATION</div><ul><li>
Requirements for this position are: a. An Associate's Degree from a recognized college or university in Nursing and a current Registered Nurse licensure in the State of Indiana, OR b. A Bachelor's Degree from a recognized college or university in health records management or a closely related field and RHIA.</li><li>
Associates Nursing Required</li><li>
Bachelors Health Information Required</li><li>
Minimum 2 years inpatient hospital coding experience</li><li>
2 years Healthcare/Medical - Health Information Systems/Technology/MIS Required</li><li>
Minimum 3 years' experience in Clinical documentation Improvement (Preferred), hospital inpatient quality chart review or Case Management</li><li>
RHIA - Registered Health Info Administrator</li><li>
RHIT - Registered Health Info Technician</li><li>
Licensed Registered Nurse</li></ul><div> 
STANDARDS OF BEHAVIOR 
Meets the Standards of Behavior as outlined in Personnel Policy and Procedure #1, Employee Relations Code. 
 
CONFIDENTIALITY/HIPAA/CORPORATE COMPLIANCE 
Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality and integrity of employee, patient, family, organizational and other medical information. Understands and supports the commitment of Methodist Hospitals in adhering to federal, state and local laws, rules and regulations governing ethical business practices for healthcare providers. 
 
DISCLAIMER - The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. The statements are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required.</div></div>

CLINICAL DOCUMENT SPECIALIST

SABINE HOSPITAL & RESEARCH CENTRE PVT LTD

We are Hiring Medical Scribe professionalsLocation - Anayara, TrivandrumSabine Hospitals &amp; Research Centre Pvt Ltd is a premier healthcare facility and a leading centre for infertility treatment. Our mission is to provide exceptional medical care and support to our patients with compassion and dedication.We are looking for a Medical Scribing professionals to join our team to support physicians by accurately documenting patient encounters and clinical information in a timely manner, ensuring complete, clear, and compliant medical records that enhance patient care and operational efficiency.Immediate joiners are preferred.Qualifications:<ul><li>Degree/Diploma in Medical scribing or Medical Transcription</li><li>1 - 2 year of experience in an accredited hospital</li><li>Internship or hospital exposure preferred</li><li>Software proficiency</li></ul>Skills:<ul><li>Strong medical terminology knowledge</li><li>Excellent listening and typing skills</li><li>Good written and verbal communication</li><li>Professional ethics, integrity, and accountability</li><li>Time management</li></ul>Responsibilities:<ul><li>Document patient encounters accurately as per physician dictation</li><li>Assist doctors during OPD, ward rounds, and procedures</li><li>Maintain patient confidentiality and data privacy</li><li>Follow hospital policies and documentation standards</li></ul>Salary should be based on interview performance &amp; experience . Should be fixed at the time of interviewInterested candidates are requested to send their updated resume to careers@sabinehospitals.com or through indeedWe look forward to reviewing your application and potentially welcoming you to our healthcare team.Contact email ID: careers@sabinehospitals.comContact Number : 9249098256Job Types: Full-time, PermanentWork Location: In personJob Types: Full-time, PermanentWork Location: In person

Medical scribe

DentalNation

Job Title: Periodontist Specialist (Part-Time | Commission-Based)Location: Al Wasl &amp; Umm Suqeim &ndash; Dubai Clinic Type: Premium Dental Clinic ChainWe are seeking an experienced Periodontist Specialist to join our premium dental clinics on a part-time, commission-based basis. The ideal candidate will provide advanced periodontal care while maintaining the highest clinical and ethical standards.Requirements:<ul><li>Specialist Periodontist license (DHA eligibility or active DHA license)</li><li>Minimum 2&ndash;3 years of clinical experience as a Periodontist (preferred)</li><li>Strong expertise in:</li><li>Non-surgical and surgical periodontal therapy</li><li>Management of periodontal disease and maintenance programs</li><li>Periodontal surgeries (flap surgery, grafting, regenerative procedures)</li><li>Implant-related periodontal procedures (preferred)</li><li>Experience with laser periodontal treatments is an advantage</li><li>Excellent diagnostic, communication, and case presentation skills</li><li>Ability to work independently and within a multidisciplinary team</li><li>Professional appearance and ethical clinical practice</li><li>Flexible availability for part-time scheduling across branches as required</li></ul>Key Responsibilities:<ul><li>Diagnose and manage periodontal conditions and gum diseases</li><li>Perform periodontal surgeries and advanced periodontal treatments</li><li>Manage periodontal emergencies and maintenance cases</li><li>Maintain accurate clinical documentation using the clinic&rsquo;s software system</li><li>Follow DHA regulations, infection control, and clinic protocols</li><li>Communicate treatment plans clearly to patients and referring dentists</li><li>Collaborate with general dentists, prosthodontists, and implantologists</li><li>Ensure high patient satisfaction and long-term treatment outcomes</li></ul>Job Type: Part-timeExperience:<ul><li>Periodontics: 2 years (Required)</li></ul>

Periodontist specialist

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