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Medical Documentation Jobs (NOW HIRING)

Ho-Chunk, Inc.

Medical Records Technician

Colchester, VT · On-site

$17.25 - $22.22/hr

Manage medical documentation by receiving, scanning, and filing all records into the appropriate electronic record system (MEDCHART) and the Soldier's hard copy record * Maintain medical records in ...

Barasch & McGarry

Medical Specialist

Manhattan, NY · On-site

Review, gather, and process medical documentation required for WTCHP and VCF claims. * Communicate clearly with clients, providers, and third-party organizations to obtain required records.

New

Rome Health

Medical Assistant

Rome, NY

$16.75 - $21.50/hr

Obtain and document vital signs and patient information * Organize and maintain patient records and medical documentation * Coordinate scheduling, testing, and follow-up appointments * Communicate ...

Rome Health

Medical Assistant

Rome, NY · On-site

$16 - $18.20/hr

Obtain and document vital signs and patient information * Organize and maintain patient records and medical documentation * Coordinate scheduling, testing, and follow-up appointments * Communicate ...

Rome Health

Medical Assistant

Verona, NY · On-site

$16 - $18.20/hr

Obtain and document vital signs and patient information * Organize and maintain patient records and medical documentation * Coordinate scheduling, testing, and follow-up appointments * Communicate ...

Snelling Staffing - El Paso/Las Cruces

Be Seen First

Bilingual Medical Scribe

El Paso, TX · On-site

$14/hr

The Bilingual Medical Scribe plays a critical role in ensuring accurate and efficient medical documentation within clinic and specialty practice settings. This position supports physicians by ...

Insight Global

Medical Assistant

Ponte Vedra, FL · On-site

$17.39 - $25.08/hr

Maintain medical documentation * Schedule care, treatment, and diagnostic tests per physician request * Process prescription requests * Process referral requests * Discuss lab results with patients

LifeHealth

Medical Records Technician

Madison, WI · On-site

$37K - $50K/yr

Upload medical documents of case managed Soldiers into Health Readiness Record (HRR). Stamp all medical documents for verification after uploading. Log all medical documents received for case ...

Lifehealth LLC

Medical Records Technician

Madison, WI · On-site

$27.30/hr

Periodic travel to Volk Field, Camp Douglas, WI for SRP events Ensure all medical documentation received from the Soldier and/or their medical team is received, scanned, and filed and placed in ...

COMPASS MEDICAL PROVIDER LLC

$35K - $44K/yr

Review and analyze medical documentation to support waiver and physical evaluation cases * Interpret Air Force and DoD medical standards and provide case recommendations * Accurately process and ...

E.N.T. Specialty Partners

Medical Assistant

Woodbridge, VA · On-site

$17.50 - $22.50/hr

Process referrals, prescriptions, and medical documentation. * Assist with billing and coding functions as needed. * Ensure compliance with HIPAA and confidentiality regulations * Patient care and ...

Scribe.ology

Medical Scribe

Mckinney, TX

$10 - $12/hr

In this dynamic position, you will work closely with physicians and healthcare professionals, accurately documenting patient encounters and medical histories. Your attention to detail and commitment ...

Scribe.ology

Medical Scribe

Irving, TX

$10 - $12/hr

In this dynamic position, you will work closely with physicians and healthcare professionals, accurately documenting patient encounters and medical histories. Your attention to detail and commitment ...

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Medical Documentation information

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How much do medical documentation jobs pay per hour?

As of Jul 4, 2026, the average hourly pay for medical documentation in the United States is $35.98, according to ZipRecruiter salary data. Most workers in this role earn between $24.04 and $50.00 per hour, depending on experience, location, and employer.

What is a Medical Documentation job?

A Medical Documentation job involves creating, managing, and maintaining patient healthcare records. Professionals in this field ensure accuracy, completeness, and compliance with legal and medical standards. They may transcribe physician notes, update electronic health records (EHR), and organize patient information for insurance and billing purposes. Strong attention to detail, knowledge of medical terminology, and familiarity with healthcare regulations are essential for this role.

How do you get a job in medical records?

To get a job in medical records, candidates typically need a high school diploma or equivalent, with some roles requiring postsecondary education or certification in health information management. Relevant skills include attention to detail, knowledge of electronic health record (EHR) systems, and understanding of healthcare privacy regulations like HIPAA. Gaining experience through internships or entry-level positions can also improve job prospects.

What are the key skills and qualifications needed to thrive in the Medical Documentation position, and why are they important?

To succeed in Medical Documentation, strong attention to detail, excellent written communication skills, and knowledge of medical terminology are essential, often supported by a relevant degree or coursework. Familiarity with electronic health record (EHR) systems, transcription software, and industry standards such as HIPAA compliance is important. Superior organizational skills, time management, and the ability to maintain confidentiality help professionals excel in this field. These skills are vital for ensuring accuracy, maintaining data integrity, and supporting efficient patient care processes.

Is clinical documentation a good career?

Medical documentation, including clinical documentation specialists, is a growing field that offers stable employment opportunities in healthcare. It requires strong attention to detail, knowledge of medical terminology, and often certification, making it a viable career for those interested in healthcare and administrative work.

How to become a medical documentation specialist?

To become a medical documentation specialist, individuals typically need a high school diploma or equivalent, followed by postsecondary education such as a certificate or associate degree in health information technology or medical coding. Certification from organizations like the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) can enhance job prospects. Strong attention to detail, knowledge of medical terminology, and proficiency with electronic health record systems are essential skills in this role.

What are some typical challenges faced by professionals in Medical Documentation roles?

Professionals in Medical Documentation often face challenges such as staying current with evolving medical terminology, managing large volumes of patient records efficiently, and ensuring accuracy while working under tight deadlines. They may also encounter difficulties navigating various electronic health record (EHR) systems and adhering to strict confidentiality and compliance requirements. Overcoming these challenges requires strong organizational skills, adaptability, and diligent attention to detail. Successful medical documentation specialists play a critical role in supporting patient care and enabling smooth clinical workflows.

What does a medical documentation specialist do?

A medical documentation specialist reviews, organizes, and maintains accurate patient records and clinical documentation. They ensure compliance with healthcare regulations, often using electronic health record (EHR) systems, and may assist with coding and billing processes to support healthcare providers' documentation needs.
More about Medical Documentation jobs
What cities are hiring for Medical Documentation jobs? Cities with the most Medical Documentation job openings:
What are the most commonly searched types of Medical Documentation jobs? The most popular types of Medical Documentation jobs are:
What states have the most Medical Documentation jobs? States with the most job openings for Medical Documentation jobs include:
What job categories do people searching Medical Documentation jobs look for? The top searched job categories for Medical Documentation jobs are:
Medical Documentation jobs near you
Infographic showing various Medical Documentation job openings in the United States as of June 2026, with employment types broken down into 2% As Needed, 49% Full Time, 32% Part Time, 1% Temporary, 15% Contract, and 1% Nights. Highlights an 94% Physical, 2% Hybrid, and 4% Remote job distribution, with an average salary of $74,847 per year, or $36 per hour.

Medical Director

Key Recovery and Life Skills Center

Seattle, WA • On-site

$250K - $300K/yr

Full-time

Medical, Dental, Vision, Retirement, PTO

Posted 13 days ago

Job description

Job Type
Full-time
Description
Key Works is seeking an experienced Medical Director to provide leadership and full operational oversight of the medical department within our residential treatment program. This role carries primary responsibility for medical operations, medication management systems, regulatory compliance, and continuous quality improvement related to patient medical care.
The Medical Director serves as the accountable owner of the medication room, medication processes, and medical policies and procedures, ensuring safe, compliant, and reliable execution across staff and shifts. This role works collaboratively with senior leadership, clinical leadership, and operations to strengthen systems, reduce risk, and support high-quality patient care.
Medical Department Leadership & Ownership:
  • Assume full responsibility for the day-to-day operations, performance, and regulatory posture of the medical department.
  • Serve as the clinical and operational lead for all medication-related processes, workflows, and staff practices.
  • Establish clear expectations, roles, and accountability for medical and medication-related staff functions.

Medication Management & Process Oversight:
  • Provide direct oversight of the med room, including medication storage, security, access controls, and environmental standards.
  • Ensure accurate medication reconciliation, MAR integrity, and alignment between orders, administration, and documentation.
  • Direct and oversee patient medication orientation and self-administration processes in accordance with policy and regulation.
  • Monitor, audit, and address medication variances, discrepancies, and errors.
  • Lead timely investigation, documentation, and follow-up of medication-related incidents.
  • Train and support RSS, nursing, and clinical staff on medication handling, documentation, and self-administration procedures.

Quality, Process Improvement & QAPI:
  • Lead medical-related QAPI initiatives with a particular focus on medication safety, reliability, and standardization.
  • Develop and track key medical and medication metrics (e.g., error rates, inventory variances, audit findings).
  • Conduct routine audits of MARs, medication workflows, and medical documentation.
  • Identify process gaps and lead corrective actions, staff re-education, and system redesign as needed.
  • Ensure Plans of Correction related to medical, or medication issues are implemented, monitored, and sustained.

Clinical Care & Oversight:
  • Conduct or oversee medical assessments upon admission and throughout treatment.
  • Monitor and manage withdrawal protocols, MOUD/MAT therapies, and co-occurring medical conditions.
  • Review patient medication regimens for safety, interactions, and appropriateness.
  • Provide education to patients and families regarding medications, recovery, and medical aspects of treatment.
  • Oversee PA, RN/BSN, MA, and medication coordinator staff.

Compliance & Documentation:
  • Ensure medical operations comply with applicable federal and state regulations, including HIPAA and 42 CFR Part 2.
  • Maintain accurate, timely, and compliant medical documentation within the electronic health record.
  • Report audit findings, trends, and concerns to the Compliance Director and leadership as appropriate.
  • Stay current on best practices, regulatory expectations, and standards related to SUD treatment and medication management.

Requirements
Qualifications:
  • Licensed medical provider (MD, DO) in Washington State.
  • Demonstrated experience with medication management, withdrawal management, and MOUD/MAT.
  • Strong experience in process improvement, auditing, and quality initiatives preferred.

Benefits:
Join our team and enjoy a comprehensive benefits package designed to support your well-being and career growth. This includes:
  • Healthcare: Company-paid medical, along with dental, and vision insurance with employer-sponsored wellness programs.
  • Paid Time Off: Generous vacation, sick leave, and 10 paid holidays, plus a flexible work schedule to accommodate your needs.
  • Retirement: 401(k) with company matching.
  • Professional Development: Access to industry-leading training and conferences, as well as tuition reimbursement for relevant courses.
  • Employee Discounts: Enjoy discounts on a variety of products and services, including travel, entertainment, and technology.

Salary Description
$250,000 - $300,000/year - DOE

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