Medical Scribe

Position Summary

The Medical Scribe supports healthcare providers by performing clerical and documentation tasks in a clinical setting. This role is responsible for operating the electronic health record (EHR) system and electronic dictation software, ensuring accurate and timely documentation of patient encounters. The Medical Scribe collaborates with clinical, administrative, technical, and support staff to facilitate effective patient care and continuity of services.This position requires initiative, attention to detail, strong communication skills, and the ability to work in a fast-paced clinical environment. Medical Scribes must maintain discretion, professionalism, and confidentiality at all times.

Responsibilities and Duties

• Record patient medical history, physical examination findings, and provider assessments.
• Document provider-dictated diagnoses, prescriptions, orders, and instructions for patients and families.
• Prepare and send referral letters and supporting documentation as directed by the provider.
• Ensure that letters, reports, and test results are distributed promptly to all providers involved in a patient’s care.
• Comply with all legal, ethical, and regulatory requirements for medical documentation and patient confidentiality (HIPAA).
• Organize, compile, and submit data for quality improvement initiatives, including physician quality reporting systems.
• Maintain MA-level access to the EHR and ensure proper use of the system.
• Proofread and edit all medical documents for accuracy in spelling, punctuation, grammar, and content.
• Assist with formatting, organizing, and tracking documentation for regulatory submissions and audits.
• Perform other related duties as assigned to support clinical operations.

Qualifications

Knowledge, Skills, and Abilities

• Knowledge of medical terminology, clinical workflows, EHR systems, and HIPAA requirements.
• Strong documentation, communication, organizational, and computer skills with attention to detail. Ability
• Ability to accurately document patient encounters, maintain confidentiality, prioritize tasks, adapt to a fast-paced clinical environment, and collaborate effectively with providers and healthcare team members.

Education

• High school diploma or equivalent required.
• Graduate of a Medical Assistant program preferred.
• Certification or certification-eligibility through AAMA (American Association of Medical Assistants) preferred.
• Basic CPR certification

Experience

• Preferred: Two years of undergraduate coursework in computers, business, healthcare, or a related field.

Physical Demands

• Regularly required to sit, stand, walk, talk, hear, and use hands to write and type.
• Must be able to reach with arms and hands, occasionally climb, balance, stoop, kneel, crouch, or crawl.
• Must be able to lift and/or move up to 10 pounds.
• Visual abilities required include close vision, depth perception, color vision, and the ability to adjust focus.

Working Environment

• Work performed in an outpatient primary care clinic with adequate lighting and climate control.
• Frequent exposure to communicable diseases, bodily fluids, and hazardous materials (biological, chemical, and low-level radiation).
• May work in a windowless environment.
• Frequent moderate noise levels due to phones, equipment, and patient interactions.
• Occasional interactions with patients, family members, or visitors who may be emotionally distressed or agitated.
• Requires moderate physical exertion and prolonged periods of standing or sitting.

Disclaimer

The above is intended to describe the job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not to be construed as an exhaustive statement of supplemental duties, responsibilities, or non-essential requirements.

Medical Associates Plus is an Equal Opportunity Employer and does not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identity and/or expression, veteran status, basis of disability or any other federal, state or local protected class.