Clinical Documentation Specialist

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Winning Assistants LLC

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51 - 200 employees

At Winning Assistants, we help doctors, healthcare professionals, and business owners save time, cut costs, and scale their operations with highly skilled, HIPAA-compliant virtual assistants. Our VAs handle tasks like admin support, medical office management, marketing, and customer service, allowing you to focus on growth.

📋 Description

• Review, analyze, and summarize large volumes of medical records for peer review cases • Extract key clinical findings, diagnoses, treatment history, medications, procedures, provider notes, and timelines • Organize complex medical information into concise and accurate summaries • Support Independent Review Organization (IRO) workflows and peer review processes • Prepare documentation and case summaries for physician reviewers • Collaborate with providers and reviewers as needed to ensure complete documentation • Provide nursing home scribing and clinical documentation support when needed • Review orders, vital signs, and patient information within nursing home EHR systems • Maintain HIPAA compliance and confidentiality when handling patient records • Adapt quickly to new technologies and evolving workflows

🎯 Requirements

• Medical or clinical background required • Nursing background strongly preferred • Experience working in healthcare, clinical operations, medical records, utilization review, medical scribing, case review, or related fields • Strong understanding of medical terminology, diagnoses, treatments, and clinical documentation • Experience reviewing, analyzing, or summarizing medical records • Ability to identify and extract relevant clinical information from complex documentation • Strong attention to detail and documentation accuracy • Must be highly tech-savvy and comfortable learning new systems quickly • Experience working across multiple EHR and EMR platforms • Excellent written and verbal English communication skills • Ability to communicate professionally with providers, reviewers, and healthcare staff • Strong critical thinking and analytical abilities • Ability to work independently with minimal supervision • Experience with any of the following platforms is highly preferred: Dane Street, ExamWorks, Propeer, GerryMD / Gerryman, PointClickCare (PCC).

🏖️ Benefits

• Dedicated HR & Contractor Support Team: Access to world-class support for questions, guidance, contract matters, and client communication. • Premium VPN Access (Optional): A secure VPN license can be provided upon request to enhance privacy and security for client-related tasks. • HIPAA & Cybersecurity Training + Certification (Provided): Access to our internal HIPAA compliance training, cybersecurity modules, and certification to help you confidently handle PHI for U.S. healthcare clients. • Top 1% VA Performance Training: Access to our proprietary training on communication, client management, productivity systems, and best practices to help you become a top-performing VA and increase long-term client retention. • Client-Approved U.S. Holidays: Contractors may take U.S. holidays off according to the client’s needs and schedule. • Client-Approved Paid or Unpaid Time Off: Time off may be granted by your client. Paid time off is optional and only if offered by the client. • Access to Tools & Resources: Templates, workflow guides, productivity tools, and client-specific SOP support to help you perform at your best. • Optional Performance-Based Incentives: Some clients may offer bonuses, incentives, or increased hours based on your performance.