Description

Clinical Documentation Specialist

The Documentation Specialist is responsible for reviewing patient charts to ensure documentation is accurate and reflects all actions, diagnoses, and advice taken or provided by the provider. The incumbent will be responsible for the minimum number of chart reviews per provider and focused reviews based on needs/prior findings.

Essential Functions & Responsibilities:

• Review and update MIPS reports and documentation requirements to ensure organizational compliance and successful Medicare review.
• Post chart review summaries to providers to identify potential opportunities based on medical visits, diagnostic outcomes, etc.
• Works closely with the team leads and management team to discuss audit reviews and provide recommendations for any training enhancements as needed.
• Ensures that documentation in the medical record accurately reflects the quality and level of care provided.

Skills & Abilities:

• Skilled in Microsoft Office platforms (Word, Excel, PowerPoint).
• Experience working with Modernizing Medicine and NexTech EMR systems is preferred.
• Strong organization, training, and process management skills.
• Strong collaboration and relationship-building skills.
• Excellent written and oral communication skills.
• Ability to learn new tasks, concepts, and can adapt to change.
• Requires the ability to work independently and establish priorities.
• Physical Requirements This position works under usual office conditions.
• The employee is required to work at a personal computer, meet deadlines, have the flexibility to travel if needed.

Qualifications

Qualifications & Experience Required:

• Successful candidates should be able to demonstrate they have three years of experience and knowledge as a Medical Assistant in Dermatology.
• Prior experience as a Medical Coder is highly desirable.
• Understanding basic dermatology coding and MIPS is highly desirable.