Clinical Documentation Quality Assurance Specialist

1 week ago


Lahore, Punjab, Pakistan beBee Careers Full time

At the forefront of healthcare excellence, we require a diligent and meticulous individual to ensure the accuracy and quality of patient medical records. This position demands a deep understanding of clinical documentation principles and the ability to analyze complex medical information with precision.

Key Responsibilities:
  • Evaluate patient records for completeness, clarity, and consistency in clinical documentation.
  • Utilize clinical judgment to analyze diagnoses, treatments, and care documentation for accuracy and adherence to established standards.
  • Identify documentation gaps, inconsistencies, or ambiguities and flag them for clarification and improvement.
  • Collaborate with internal teams to provide feedback and support documentation improvement initiatives.
  • Ensure compliance with internal standards, HIPAA regulations, and external quality and audit requirements.
  • Monitor documentation trends and contribute to internal reviews and quality improvement initiatives.
  • Maintain confidentiality and attention to detail in all documentation processes.
  • Work independently with a focus on record review, devoid of direct patient communication.
Qualifications:
  • Bachelor's degree in Nursing, Health Information Management, or a related healthcare field.
  • Minimum 2 years of experience in clinical documentation review, medical records, or healthcare quality.
  • Strong clinical knowledge and understanding of medical terminology and care workflows.
  • Fluent in English (spoken and written) with exceptional communication and documentation skills.
  • Comfortable working in an evening shift environment, 6:00 PM to 2:00 AM, 6 days a week.
  • Proficiency in using Electronic Health Record (EHR) systems.
  • Certification in Clinical Documentation Improvement (CCDS, CDIP) is highly desirable but not required.


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