clinical documentation specialist

Medical University of South Carolina

<div></div><div><div><ul><li>R-0000062673
</li> <div></div><li>Remote
</li> </ul></div><div></div><div><ul><li>South Carolina
</li> </ul></div><div></div><div><ul><li>Healthcare Support
</li> </ul></div><div></div><div><ul><li>Clinical &amp; Research Support Services
</li> </ul></div><div></div><div><ul><li>Full Time
</li> </ul></div><div></div><div><ul><li>Hospital Authority (MUHA)</li></ul></div></div>
<br><div><p><b>Job Description Summary</b></p>
The RN (Registered Nurse) &ndash; Clinical Documentation Specialist I report to their respective Manager, Clinical Documentation. Under general supervision, the RN &ndash; Clinical Documentation Specialist I conduct reviews of<br>
inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and collaborate with and facilitate appropriate provider documentation to accurately reflect appropriate DRG (Diagnosis Related Group) assignment, patient severity of illness and risk of mortality. In addition, the CDI (Clinical Documentation Integrity) specialist risk adjusts for expected mortality/length of stay and clinically validates key diagnoses. The RN &ndash; Clinical Documentation Specialist I is responsible for a baseline understanding of interpreting quality metrics and participates in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system.<p></p><p><b>
Entity</b></p>
Medical University Hospital Authority (MUHA)<p></p><p><b>
Worker Type</b></p>
Employee<p></p><p><b>
Worker Sub-Type
</b></p>Regular<p></p><p><b>
Cost Center</b></p>
CC005073 CHS - Clinical Documentation<p></p><p><b>
Pay Rate Type</b></p>
Salary<p></p><p><b>
Pay Grade</b></p>
Health-28<p></p><p><b>
Scheduled Weekly Hours</b></p>
40<p></p><p><b>
Work Shift</b></p><p></p><p><b>
Job Description</b></p><p>
The RN (Registered Nurse) &ndash; Clinical Documentation Specialist I report to their respective Manager, Clinical Documentation. Under general supervision, the RN &ndash; Clinical Documentation Specialist I conduct reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and collaborate with and facilitate appropriate provider documentation to accurately reflect appropriate DRG (Diagnosis Related Group) assignment, patient severity of illness and risk of mortality. In addition, the CDI (Clinical Documentation Integrity) specialist risk adjusts for expected mortality/length of stay and clinically validates</p><p>
key diagnoses. The RN &ndash; Clinical Documentation Specialist I is responsible for a baseline understanding of interpreting quality metrics and participates in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system.</p><p></p><p><b>
Additional Job Description</b></p><p>
Bachelor's degree in nursing from an accredited school of nursing required and at least five years' clinical nursing experience preferred. Strong clinical experience and critical thinking skills required. Extensive knowledge of patient care, and knowledge of clinical measurement tools and clinical outcomes; ability to</p><p>
establish cooperative working relationships with diverse groups and individuals, medical staff and other health care disciplines. Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.</p><p></p><div>
<div><p><b>
Physical Requirements</b></p></div>
<div><ul><li><p><b>
Mobility &amp; Posture</b></p></li></ul></div>
<div><ul><li><p>
Standing: Continuous</p></li></ul></div>
<div><ul><li><p>
Sitting: Continuous</p></li></ul></div>
<div><ul><li><p>
Walking: Continuous</p></li></ul></div>
<div><ul><li><p>
Climbing stairs: Infrequent</p></li></ul></div>
<div><ul><li><p>
Working indoors: Continuous</p></li></ul></div>
<div><ul><li><p>
Working outdoors (temperature extremes): Infrequent</p></li></ul></div>
<div><ul><li><p>
Working from elevated areas: Frequent</p></li></ul></div>
<div><ul><li><p>
Working in confined/cramped spaces: Frequent</p></li></ul></div>
<div><ul><li><p>
Kneeling: Infrequent</p></li></ul></div>
<div><ul><li><p>
Bending at the waist: Continuous</p></li></ul></div>
<div><ul><li><p>
Twisting at the waist: Frequent</p></li></ul></div>
<div><ul><li><p>
Squatting: Frequent</p></li></ul></div>
<div><ul><li><p><b>
Manual Dexterity &amp; Strength</b></p></li></ul></div>
<div><ul><li><p>
Pinching operations: Frequent</p></li></ul></div>
<div><ul><li><p>
Gross motor use (fingers/hands): Continuous</p></li></ul></div>
<div><ul><li><p>
Firm grasping (fingers/hands): Continuous</p></li></ul></div>
<div><ul><li><p>
Fine manipulation (fingers/hands): Continuous</p></li></ul></div>
<div><ul><li><p>
Reaching overhead: Frequent</p></li></ul></div>
</div><div>
<div><ul><li><p>Reaching in all directions: Continuous</p></li></ul></div>
<div><ul><li><p>
Repetitive motion (hands/wrists/elbows/shoulders): Continuous</p></li></ul></div>
<div><ul><li><p>
Full use of both legs: Continuous</p></li></ul></div>
<div><ul><li><p>
Balance &amp; coordination (lower extremities): Frequent</p></li></ul></div>
<div><ul><li><p><b>
Lifting &amp; Force Requirements</b></p></li></ul></div>
<div><ul><li><p>
Lift/carry 50 lbs. unassisted: Infrequent</p></li></ul></div>
<div><ul><li><p>
Lift/lower 50 lbs. from floor to 36&rdquo;: Infrequent</p></li></ul></div>
<div><ul><li><p>
Lift up to 25 lbs. overhead: Infrequent</p></li></ul></div>
<div><ul><li><p>
Exert up to 50 lbs. of force: Frequent</p></li></ul></div>
<div><ul><li><p><i>
Examples:</i></p></li></ul></div>
<div><ul><li><p>
Transfer 100 lb. non-ambulatory patient = 50 lbs. force</p></li></ul></div>
<div><ul><li><p>
Push 400 lb. patient in wheelchair on carpet = 20 lbs. force</p></li></ul></div>
<div><ul><li><p>
Push patient stretcher one-handed = 25 lbs. force</p></li></ul></div>
<div><ul><li><p><b>
Vision &amp; Sensory</b></p></li></ul></div>
<div><ul><li><p>
Maintain corrected vision 20/40 (one or both eyes): Continuous</p></li></ul></div>
<div><ul><li><p>
Recognize objects (near/far): Continuous</p></li></ul></div>
<div><ul><li><p>
Color discrimination: Continuous</p></li></ul></div>
<div><ul><li><p>
Depth perception: Continuous</p></li></ul></div>
<div><ul><li><p>
Peripheral vision: Continuous</p></li></ul></div>
<div><ul><li><p>
Hearing acuity (with correction): Continuous</p></li></ul></div>
</div><div>
<div><ul><li><p>Tactile sensory function: Continuous</p></li></ul></div>
<div><ul><li><p>
Gross motor with fine motor coordination: Continuous</p></li></ul></div>
<div><ul><li><p><i>
Selected Positions:</i></p></li></ul></div>
<div><ul><li><p>
Olfactory (smell) function: Continuous</p></li></ul></div>
<div><ul><li><p>
Respirator use qualification: Continuous</p></li></ul></div>
<div><ul><li><p><b>
Work Environment &amp; Conditions</b></p></li></ul></div>
<div><ul><li><p>
Effective stress management: Continuous</p></li></ul></div>
<div><ul><li><p>
Rotating shifts: Frequent</p></li></ul></div>
<div><ul><li><p>
Overtime as required: Frequent</p></li></ul></div>
<div><ul><li><p>
Latex-safe environment: Continuous</p></li></ul></div><br>
<p></p>
</div><p></p><p><i>
If you like working with energetic enthusiastic individuals, you will enjoy your career with us!</i></p><p></p><p>
The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.
</p><p></p><p>Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees</p></div>

Clinical Documentation Specialist I

Oak Street Health, part of CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Title: </b>Medical Scribe - Float</p><p></p><p><b>
Company: </b>Oak Street Health</p><p></p><p><b>
Location: </b>Various</p><p></p><p><b>
Role Description:</b></p><p></p><p>
The purpose of a Clinical Informatics Specialist (CIS or Medical Scribe) at Oak Street Health is to support our primary care providers with clinical documentation so that they can focus on providing exceptional care to our patients. Scribes assist providers throughout the patient care journey - huddling each morning to plan for the day's visits, joining them in the exam room to observe and document, and touching base after the visit to assist with next steps.</p><p></p><p>
Beyond the typical Scribe role, these important care team members serve as clinical documentation assistants to their paired provider. Internally, we call them CISs (Clinic Informatics Specialists) in recognition of their important role in supporting accurate, specific, and timely clinical documentation. In addition to observing and documenting all patient encounters in real time, our Scribes become experts in our value-based care model and the documentation and care of chronic conditions, including ICD-10 and CPT coding. Scribes use this expertise to help providers identify and help close care gaps. Scribes receive extensive on-the-job training in clinical workflows, value-based medicine, preventative care for chronic conditions, accurate and specific documentation, population health data streams, and team based care.</p><p></p><p>
Because our patients and providers rely on our Scribes, the ideal candidate should commit at least 1-2 years to this role. This is an excellent opportunity for pre-med track individuals looking to gain practical, paid experience in a clinical setting before applying to an MD/DO/PA/NP program, as well as those pursuing careers in Health Informatics, Public Health, Healthcare Administration, Medical Coding, and other related fields.</p><p></p><p><b>
Responsibilities:</b></p><ul><li>
Documenting Patient Encounters ~ 80%<ul><li>
Joining the provider in the exam room to observe patient visits</li><li>
Documenting patient encounters in a structured note, including the history of the present illness, assessment, plan, and physical exam</li><li>
Assigning appropriate CPT and ICD-10 codes</li><li>
Preparing After Visit Summaries</li><li>
Consulting with provider to ensure accurate and specific documentation</li></ul></li><li>
Clinical Documentation Improvement ~ 10%<ul><li>
Requesting and reviewing medical records</li><li>
Leveraging Oak Street's population health tools to support clinical documentation improvement</li><li>
Preparing for and supporting Daily Huddles and Clinical Documentation Reviews</li><li>
Consulting with provider on clinical documentation opportunities</li></ul></li><li>
Administrative support for your provider and care team ~ 10%<ul><li>
Placing orders and referrals</li><li>
Addressing tasks</li><li>
Supporting the care team with additional responsibilities related to clinical documentation</li></ul></li><li>
Other duties as assigned</li></ul><p></p><p><b>
What we're looking for</b></p><p></p><p><b>
Knowledge</b></p><ul><li>
Knowledge of medical terminology and common medications, either from a pre-medical degree or prior clinical experience [required]</li><li>
Prior clinical experience, including shadowing and/or volunteering [strongly preferred]</li><li>
Prior scribe or transcription experience [preferred but not required]</li></ul><p></p><p><b>
Skills</b></p><ul><li>
Advanced listening and communication skills [required]</li><li>
Strong computer literacy and ability to learn new technical workflows [required]</li><li>
Fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities we serve [required where indicated]</li></ul><p></p><p><b>
Abilities</b></p><ul><li>
Ability to adapt to new workflows and to quickly learn new concepts and skills [required]</li><li>
Ability to type 70+ words per minute [strongly preferred]</li><li>
Ability and willingness to take direction and be a member of a team providing patient care, including adapting to the provider's working style [required]</li><li>
Ability to be a self-starter within your role scope</li><li>
Excellent job attendance including ability to work in-person in our clinics (Our providers count on you.) [required]</li><li>
Ability to commit to at least 1 year in role (2+ is ideal) [required]</li><li>
Ability to work approximately 40-45 hours per week during clinic hours (full time position) with predictable hours and break times [required]</li><li>
Compliance with hospital and Oak Street Health policies, including HIPAA [required]</li><li>
US work authorization [required]</li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$17.00 - $31.30<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
We anticipate the application window for this opening will close on: 12/25/2026<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Remote Medical Scribe Float

Carilion Clinic

<div><h2 class="jobSectionHeader"><b>Employment Status:
</b></h2>Full time
<h2 class="jobSectionHeader"><b>Shift:
</b></h2>Any Day, Any Shift (United States of America)
<h2 class="jobSectionHeader"><b>Facility:
</b></h2>1 Health Cir - Lexington
<h2 class="jobSectionHeader"><b>Requisition Number:
</b></h2>R160753 SCRIBE (Open)&amp;#xa;&amp;#xa;
<h1 class="jobSectionHeader"><b>How You&rsquo;ll Help Transform Healthcare:
</b></h1>The Scribe facilitates and assists in the completion of the physician's medical records and patient documentation in a professional and timely manner.&amp;#xa;&amp;#xa;
<p>The Scribe
</p><ul><li><p>Accompanies a physician through the duties of patient care during the course of each work shift, while updating the medical record in real time. Transcribing details of the physical exam and elements of the chart. This includes assimilating results from any lab tests, imaging tests, or medications ordered by the physician. A scribe may also be present to record a physician's consultations with family members or other physicians about a specific patient's case.
</p></li><li><p>Reminds physician on the progress of lab, X-ray, or other patient evaluation data and transcribing the results into patient charts so that a patient's workup is complete and the physician can make sound treatment decisions.
</p></li><li><p>Documents procedures performed by the physician or any other healthcare professional, including nurses and physician assistants.
</p></li><li><p>May assist in initiating pages to the consultants for the physician.
</p></li><li><p>Masters the use of the EPIC EMR, and the PACS imaging system.
</p></li><li><p>Performs other duties as required based upon site-specific or department specific requirements.
</p></li><li><p>When working with PPEs will assist with mask drop off and retrieval, bleach changes, replacement of PPE and employee exposure logs.
</p></li><li><p>If working as documentation specialist will implement appropriate and timely referrals to physician advisors.
</p></li><li><p>May collect data showing activities performed and improvements made.
</p></li><li><p>May perform pre-billing reviews of clinical documentation
</p></li><li><p>Demonstrates a willingness to maintain awareness of the business of medicine and changes in coding and billing in a health care setting including, but not limited to, Value Based Medicine, Readmission Reduction Programs, provider updates and the business of medicine directly impacting physician practices that may include updates from CMS that may impact billing, documentation and coding.
</p></li></ul><p></p>&amp;#xa;&amp;#xa;
<h1 class="jobSectionHeader"><b>What We Require:
</b></h1><p><b>Education: </b>Associate's degree or equivalent required.<br>
</p><p><br>
<b>Experience: </b>1-2 years of experience working with the public in a healthcare setting required.<br>
<br>
</p><p><b>Other: </b>Excellent PC, typing and interpersonal and verbal communication skills required. Familiar with medical terminology required.
</p><p></p><p>This job description is only meant to be a representative summary of the major responsibilities and accountabilities performed by the incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
</p>&amp;#xa;&amp;#xa;
<p></p><p><b>Recruiter:
</b></p>KATHRYN LUSHER
<p><b>Recruiter Email:
</b></p>kjlusher@carilionclinic.org
<p></p><p><b>For more information, contact the HR Service Center at 1-800-599-2537.
</b></p><p></p><p>Carilion Clinic is an Equal Opportunity Employer: We provide equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, national origin, age (40 or older), disability, genetic information, or veterans status. Carilion is a Drug-Free Workplace. For more information or for individuals with disabilities needing special assistance with our online application process contact Carilion HR Service Center at 800-599-2537, 8:00 a.m. to 4:30 p.m., Monday through Friday.
</p><p></p><p>For more information on E-Verify: https://www.carilionclinic.org/eoe-e-verify-and-right-work-policies
</p>&amp;#xa;&amp;#xa;
<h2 class="jobSectionHeader"><b>Benefits, Pay and Well-being at Carilion Clinic<br>
</b></h2><br>
<p>Carilion understands the importance of prioritizing your well-being to help you develop and thrive. That&rsquo;s why we offer a well-rounded benefits package, and many perks and well-being resources to help you live a happy, healthy life &ndash; at work and when you&rsquo;re away.<br>
</p><p><br>
When you make your tomorrow with us, we&rsquo;ll enhance your potential to realize the best in yourself. Below are benefits available to you when you join Carilion:<br>
</p><br>
<ul><li>Comprehensive Medical, Dental, &amp; Vision Benefits
</li><li>Employer Funded Pension Plan, vested after five years (Voluntary 403B)
</li><li>Paid Time Off (accrued from day one)
</li><li>Onsite fitness studios and discounts to our Carilion Wellness centers
</li><li>Access to our health and wellness app, Personify Health
</li><li>Discounts on childcare
</li><li>Continued education and training</li></ul></div>

SCRIBE

Nao Medical

<p></p><div><h2 class="jobSectionHeader"><b>About the Company</b></h2>
<p>
Nao Medical is a rapidly growing, multi-site, AI-infused healthcare practice providing high-quality, accessible care across primary care, urgent care, occupational health, mental health, and nutrition.</p>
<p>
Our AI-first operating model empowers clinical teams to focus on patient care while optimizing workflows with proprietary technology. As we expand, we seek mission-driven professionals who are detail-oriented, tech-savvy, and committed to accurate clinical documentation.</p>
<h2 class="jobSectionHeader"><b>
Position Overview:</b></h2>
<p>
We are hiring a Medical Scribe to support our Canarsie Clinic providers by documenting patient encounters in real time, ensuring accurate and compliant medical records.</p>
<p>
The ideal candidate will:</p>
<ul><li>
<p>Have 1&ndash;2 years of experience in clinical documentation or healthcare support.</p>
</li><li>
<p>Be proficient in EMR systems (e.g., eClinicalWorks).</p>
</li><li>
<p>Demonstrate strong attention to detail, organization, and HIPAA compliance.</p>
</li></ul>
<p>This role provides hands-on exposure to multi-specialty clinical workflows, opportunities for cross-training, and career growth in healthcare operations.</p>
<h2 class="jobSectionHeader"><b>
Why Join Nao Medical</b></h2>
<ul><li>
<p>Clinical Exposure: Work alongside providers in a fast-paced, multi-specialty setting.</p>
</li><li>
<p>Skill Growth: Develop expertise in EMR documentation, coding standards, and workflow optimization.</p>
</li><li>
<p>Career Development: Gain mentorship, advancement opportunities, and access to continued education.</p>
</li><li>
<p>Meaningful Impact: Ensure accurate clinical documentation that supports high-quality, value-based care.</p>
</li></ul>
<h2 class="jobSectionHeader"><b>Primary Responsibilities</b></h2>
<h2 class="jobSectionHeader"><b>Documentation &amp; EMR Support</b></h2>
<ul><li>
<p>Accurately document patient encounters in real time under provider supervision.</p>
</li><li>
<p>Enter patient histories, exam findings, diagnoses, treatment plans, orders, and test results into the EMR.</p>
</li><li>
<p>Maintain complete, timely, and compliant clinical documentation in accordance with HIPAA, OSHA, and internal standards.</p>
</li><li>
<p>Assist providers in updating charts, templates, and clinical documentation workflows.</p>
</li></ul>
<h2 class="jobSectionHeader"><b>Patient Intake &amp; Workflow Support</b></h2>
<ul><li>
<p>Assist with patient intake by gathering non-clinical information such as chief complaints, medical history updates, and visit-related documentation.</p>
</li><li>
<p>Prepare charts, forms, and visit templates prior to patient encounters.</p>
</li><li>
<p>Support patient flow coordination and communicate effectively with providers, Medical Assistants, and front desk staff.</p>
</li><li>
<p>Retrieve prior records, lab results, imaging, or documentation as requested by providers.</p>
</li><li>
<p>Help reduce provider administrative burden to improve clinic efficiency and patient experience.</p>
</li></ul>
<h2 class="jobSectionHeader"><b>Collaboration &amp; Continuous Learning</b></h2>
<ul><li>
<p>Work closely with providers, Medical Assistants, Patient Care Associates, and administrative teams to support smooth clinic operations.</p>
</li><li>
<p>Participate in ongoing training to improve documentation accuracy, EMR proficiency, and workflow efficiency.</p>
</li><li>
<p>Adapt to evolving operational and clinical support needs within the clinic environment.</p>
</li></ul>
<h2 class="jobSectionHeader"><b>Job Requirements</b></h2>
<p>
Education &amp; Certification:</p>
<ul><li>
<p>High school diploma or associate degree required; healthcare-related coursework preferred.</p>
</li><li>
<p>Medical Scribe certification or prior clinical documentation experience preferred.</p>
</li></ul>
<p>Experience &amp; Skills:</p>
<ul><li>
<p>1&ndash;2 years in medical scribing, clinical documentation, or related healthcare support.</p>
</li><li>
<p>Proficiency with EMR systems (e.g., eClinicalWorks) preferred.</p>
</li><li>
<p>Strong typing, spelling, and grammar skills.</p>
</li><li>
<p>Excellent communication and interpersonal skills.</p>
</li><li>
<p>Detail-oriented, adaptable, and able to multitask in a fast-paced environment.</p>
</li><li>
<p>Tech-savvy with strict commitment to patient confidentiality.</p></li></ul><br>
<p></p>
<p>
Schedule &amp; Commitment</p>
<ul><li>
<p>Full-time, on-site</p>
</li><li>
<p>Flexible schedule: Monday&ndash;Saturday, 8&ndash;12 hour shifts, rotating weekends as needed.</p>
</li></ul>
<p>Performance Expectations &amp; Deliverables</p>
<ul><li>
<p>Ensure complete, accurate, and timely documentation of all patient encounters.</p>
</li><li>
<p>Maintain compliance with all legal, regulatory, and internal documentation standards.</p>
</li><li>
<p>Support providers to maximize efficiency and patient satisfaction.</p>
</li><li>
<p>Engage in continuous learning and EMR workflow optimization.</p>
</li></ul>
<p>Benefits</p>
<ul><li>
<p>Medical, Dental, Vision, Basic Life, and Short-Term Disability Insurance (employee + dependents).</p>
</li><li>
<p>Paid Family and Disability Leave; FMLA eligibility.</p>
</li><li>
<p>401(k) Retirement Plan.</p>
</li><li>
<p>Paid Time Off (PTO).</p>
</li><li>
<p>Free care for employees and discounted care for family across all Nao Medical locations.</p>
</li><li>
<p>Leadership and career growth opportunities.</p>
</li></ul>
<p>Legal &amp; Compliance Notes</p>
<ul><li>
<p>This job description is intended to comply with US labor laws and provide clear expectations.</p>
</li><li>
<p>Duties may change based on operational needs, but all responsibilities will remain consistent with MA/PCA scope of practice.</p>
</li><li>
<p>Employee must adhere to all safety, privacy, and regulatory standards (HIPAA, OSHA, and state medical guidelines).</p></li></ul></div><p></p>

Clinical Scribe

Savista

<div><p>Here at Savista, we enable our clients to navigate the biggest challenges in healthcare: quality clinical care with positive patient experiences and optimal financial results. We partner with healthcare organizations to problem solve and deliver revenue cycle improvement services that enable their success, support their patients, and nurture their communities, all while living our values of Commitment, Authenticity, Respect and Excellence (CARE).</p><p></p><p>
The Pro Fee Coder will review clinical documentation to assign and sequence diagnostic and procedural codes for specific patient types to meet the requirements of hospital data or physician data retrieval for billing and reimbursement. Coder II may validate APC calculations to accurately capture the diagnoses/procedures documented in the clinical record for hospitals. The Coder II performs documentation review and assessment for accurate abstracting of clinical data to meet regulatory and compliance requirements. Coder II may interact with client staff and providers.</p><p></p><p>
DUTIES AND RESPONSIBILITIES:</p><ul><li>
Select and sequence ICD-10, and/or CPT/HCPCS codes for designated patient types which may include but not limited to: Ancillary (Diagnostic)/ Recurring; Hospital, Clinic; Physician Pro Fee; Technical Fee or Evaluation and Management, any associated chart capturing with any patient type.</li><li>
Review and analyze facility records to ensure that APC assignments and/or Evaluation and Management codes accurately reflect the diagnoses/procedures documented in the clinical record.</li><li>
Abstract clinical data from the record after documentation review to ensure that it is adequate and appropriate to support diagnoses, procedures and discharge disposition is selected.</li><li>
Complete assigned work functions utilizing appropriate resources. May act as a resource with client staff for data integrity, clarification and assistance in understanding and determining appropriate and compliant coding practices including provider queries.</li><li>
Maintain strict patient and provider confidentiality in compliance with all HIPAA Guidelines.</li><li>
Participate in client and Savista staff meetings, trainings, and conference calls as requested and/or required.</li><li>
Maintain current working knowledge of ICD-10 and/or CPT/HCPCS and coding guidelines, government regulations, protocols and third-party requirements regarding coding and/or billing.</li><li>
Participate in continuing education activities to enhance knowledge, skills, and maintain current credentials.</li></ul><p></p><p><b>
SKILLS AND QUALIFICATIONS:</b></p><ul><li>
Candidates must successfully pass pre-employment skills assessment. Required:</li><li>
An active AHIMA (American Health Information Association) credential including but not limited to RHIA, RHIT, CCS, CCA, or an active AAPC (American Academy of Professional Coders) credentials COC (formerly CPC-H), CCS-P, or CPC or related specialty credential.</li><li>
Two years of recent and relevant hands-on coding experience</li><li>
Knowledge of medical terminology, anatomy and physiology, pharmacology, pathophysiology, as well as ICD-10 and CPT/HCPCS code sets</li><li>
Ability to consistently code at 95% threshold for quality while maintaining client-specific and/or Savista production and/or quality standards</li><li>
Proficient computer knowledge including MS Office including the ability to enter data, sort and filter excel files, (Outlook, Word, Excel)</li><li>
Must display excellent interpersonal and problem-solving skills with all levels of internal and external customers</li></ul><p></p><p>
PREFFERED SKILLS:</p><ul><li>
Recent and relevant experience in an active production coding environment strongly preferred</li><li>
Associates degree in HIM or healthcare-related field, or combination of equivalent education and experience</li><li>
Experience using RCx, Cerner, NextGen (a plus)</li><li>
Academic and Split-Share experience</li></ul><p></p><p>
Note: Savista is required by state specific laws to include the salary range for this role when hiring a resident in applicable locations. The salary range for this role is from $22.08 - $34.69 an hour. However, specific compensation for the role will vary within the above range based on many factors including but not limited to geographic location, candidate experience, applicable certifications, and skills.</p><p></p><p>
SAVISTA is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.</p><p></p><p>
California Job Candidate Notice</p></div>

Profee Coder - Hospitalist

Shasta Community Health Center

<div><h1 class="jobSectionHeader"><b>Base Salary: $22.00 - $32.50 / hour</b></h1>
<p><b>
Temporary position</b></p>
<h1 class="jobSectionHeader"><b>
JOB SUMMARY</b></h1>
<h1 class="jobSectionHeader"><b>Medical Scribes are individuals trained in medical documentation who assist a provider throughout their shift. The primary goal is to increase the efficiency and productivity of the physician. It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients following all local, state and federal guidelines for documentation into the electronic health record system. The Medical Scribe will be responsible for clearly recording each patient's symptoms, history, physical exam and documenting the diagnosis. This position will have no direct involvement in patient care but has an interdepartmental role in assisting nursing and front office staff.</b></h1>
<h1 class="jobSectionHeader"><b>JOB DUTIES AND RESPONSIBILITIES</b></h1>
<ul><li>The primary role of the Medical Scribe is to assist the clinician with documentation of each patient&rsquo;s medical chart during his or her visit.</li><li>
Accompany the clinician into the patient examination area to transcribe a history and physical examination as given by the patient and physician.</li><li>
Document any procedures performed by the clinician or nurses, on the electronic medical chart.
</li><li>Is an expert in the use of various templates and documentation techniques available in the EHR system and uses these tools efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reporting.</li><li>
Transcribes any consultations or discussions with family members and/or the clinician.</li><li>
Completes the patient&rsquo;s chart by transcribing results of any labs, x-rays, or other evaluations. In doing so, the scribe continuously checks on the progress of this data to get the patient&rsquo;s workup complete so that the clinician is able to make his or her decisions regarding that patient.</li><li>
Orders in-house testing, Immunizations, lab testing, diagnostic testing along with generating referrals.</li><li>
Lists all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.</li><li>
Other duties as assigned.</li></ul>
<p><b>
Optional Trainable Skills
</b></p><p>A Scribe can be trained to handle Patient Portal tasks for your assigned provider and chart abstraction.
</p><h1 class="jobSectionHeader"><b>KNOWLEDGE, SKILLS, AND ABILITIES</b></h1>
<ul><li>Recognition of physical exam process and ability to record exam details quickly and accurately.</li><li>
Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion.</li><li>
Strong attention to detail.</li><li>
Computer proficiency in Windows environment and ability to quickly learn new applications.</li><li>
Ability to communicate effectively in the English language in person, by phone and in writing.</li><li>
Ability to type 45 WPM or greater
</li></ul><h1 class="jobSectionHeader"><b>EDUCATION &amp; EXPERIENCE</b></h1>
<ul><li>High school diploma or equivalent.</li><li>
One year experience in healthcare field or minimum 2 years of college education.</li></ul>
<h1 class="jobSectionHeader"><b>PREFERRED QUALIFICATIONS</b></h1>
<ul><li>2-4 years of college education desired with Medical Terminology, Anatomy and Physiology coursework/degree.</li><li>
Experience working in an outpatient clinic or doctor&rsquo;s office.</li><li>
Medical Transcriptionist experience.</li><li>
Typing 60 WPM or greater.</li></ul></div><p></p>

Medical Scribe (Fellowship) Temporary Position

Coastal Eye Group

<p>This position is responsible for providing accurate documentation and summarization of the ocular examination and recommendations while maintaining patient flow and communication regarding appointments status.</p><p>Job Type: Full-time</p><p>Benefits:</p><ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li></ul><p>Medical Specialty:</p><ul><li>Ophthalmology</li></ul><p>Work Location: In person</p>

Ophthalmic Scribe/Technician

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