Medical Documentation/Records Specialist
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Key skills for this role
About the Role
AL ZAABI GROUP is hiring a Medical Documentation Specialist to review, verify, and maintain clinical documentation in EHR systems. The role requires knowledge of medical terminology, ICD-10/CPT, and experience with electronic health records.
Key Skills for This Role
Responsibilities
- Review, verify, and maintain accurate clinical documentation in EHR systems
- Ensure completeness and accuracy of patient medical records
- Work closely with physicians, coders, and healthcare professionals to resolve documentation queries
- Maintain compliance with healthcare documentation standards and regulatory requirements
- Support ICD 10/CPT documentation processes and documentation improvement initiatives
- Perform quality checks and audits on medical records
- Update patient information while ensuring confidentiality and data security
- Assist in improving documentation workflows and operational efficiency
- Prepare reports related to documentation quality and compliance
- Maintain high standards of documentation accuracy and turnaround time
Requirements
- Strong knowledge of Medical Terminology
- Experience with Electronic Health Records (EHR)
- Understanding of Clinical Documentation Improvement (CDI)
- Familiarity with ICD 10/CPT documentation
- Excellent written communication skills
- High attention to detail
Full Job Posting
Key Responsibilities
- Review, verify, and maintain accurate clinical documentation in Electronic Health Record (EHR) systems.
- Ensure completeness and accuracy of patient medical records.
- Work closely with physicians, coders, and healthcare professionals to resolve documentation queries.
- Maintain compliance with healthcare documentation standards and regulatory requirements.
- Support ICD 10/CPT documentation processes and documentation improvement initiatives.
- Perform quality checks and audits on medical records.
- Update patient information while ensuring confidentiality and data security.
- Assist in improving documentation workflows and operational efficiency.
- Prepare reports related to documentation quality and compliance.
- Maintain high standards of documentation accuracy and turnaround time.
Required Skills
- Strong knowledge of Medical Terminology.
- Experience with Electronic Health Records (EHR).
- Understanding of Clinical Documentation Improvement (CDI).
- Familiarity with ICD 10/CPT documentation.
- Excellent written communication skills.
- Strong analytical and organizational abilities.
- High attention to detail.
- Knowledge of Microsoft Office applications.
- Ability to work independently and collaboratively.
Compensation
- Pay: AED 2,500 AED 3,000 per month.
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