Medical Scribe

Job Description: Medical Scribe

Position Overview: We are seeking a highly skilled and detail-oriented Medical Scribe to join our medical office team. As a clinical documentation expert, you will play a vital role in supporting our healthcare providers by ensuring accurate and efficient documentation of patient encounters. This position demands a high level of professionalism, confidentiality, and adherence to healthcare regulations.

Medical Scribe Job Role

Key Responsibilities:

• Accompany Physicians: Join physicians during patient examinations to record detailed notes of the visit.

• Transcription: Accurately transcribe patient medical history, physical examination reports, diagnoses, treatment plans, and other relevant healthcare data.

• Documentation: Document procedures, lab results, and other pertinent information in electronic medical records (EMRs).

• EMR Navigation: Assist healthcare professionals in navigating EMRs and managing patient flow efficiently.

• Real-Time Charting: Provide real-time charting for physicians during medical procedures and consultations.

• Communication: Communicate with medical staff to clarify information and ensure accurate documentation.

• Lab Work Management: Assist in managing electronic lab work, including monitoring results, ordering additional tests, and ensuring data accuracy.

• Confidentiality: Maintain strict confidentiality and adhere to all applicable laws and regulations, including HIPAA.

• Patient Information Transfer: Handle the efficient and effective transfer of patient information into our EMR database to support patient care during each visit.

• Observation and Documentation: Observe patient visits in the examination room and document encounters in their entirety, including history of present illnesses, examination, assessment, and treatment plan.

• Coding: Prepare ICD-10 CM, CPT, and HCPCS codes.

• Document Preparation: Assemble all necessary documents prior to patient visits.

• Collaboration: Collaborate one-on-one with providers to ensure clinical documentation accuracy and specificity.

• Support: Support medical staff with additional responsibilities related to clinical documentation.

• Typing Speed: Achieve an average typing speed of 70+ words per minute.

• Other Duties: Perform other duties as assigned.

Qualifications:

• Strong attention to detail and accuracy.

• Excellent communication and interpersonal skills.

• Proficiency in using electronic medical records (EMR) systems.

• Ability to work in a fast-paced environment.

• Knowledge of medical terminology and healthcare documentation practices.

• Commitment to maintaining patient confidentiality and complying with HIPAA regulations.

Preferred Experience:

• Previous experience as a medical scribe or in a similar role.

• Familiarity with medical office procedures and workflows.

• Previous office setting

• Previous medical experience

Working Conditions:

• Office setting working with providers directly and other staff

• Work primarily in a clinical setting, accompanying physicians during patient visits.

Benefits:

• Medical, Dental, Vision
• PTO
• Medical Scrubs
• 401k
• Weekends Off