medical documentation specialist

fisher house of lawnside

Job Summary We are seeking a detail-oriented and motivated Medical Scribe to join our healthcare team. The Medical Scribe will play a crucial role in assisting healthcare providers by accurately documenting patient encounters in real-time. This position requires a strong understanding of medical terminology, anatomy, and physiology, as well as proficiency in medical documentation systems. The ideal candidate will thrive in a fast-paced environment and be committed to enhancing the efficiency of patient care.Responsibilities<ul><li>Accurately transcribe physician-patient encounters during examinations and procedures.</li><li>Document medical histories, physical exams, and treatment plans in electronic health records (EHR).</li><li>Ensure all medical documentation is complete, accurate, and compliant with regulatory standards.</li><li>Assist healthcare providers with administrative tasks as needed, including managing patient records and scheduling.</li><li>Maintain confidentiality of patient information in accordance with HIPAA regulations.</li><li>Collaborate with medical staff to facilitate efficient patient flow within the office or ER setting.</li></ul>Skills<ul><li>Proficiency in medical records management and medical documentation processes.</li><li>Strong knowledge of anatomy and physiology to accurately document clinical findings.</li><li>Familiarity with medical terminology relevant to various specialties.</li><li>Experience with EHR systems and data entry; ability to type efficiently while maintaining accuracy.</li><li>Excellent communication skills, both verbal and written, to effectively interact with healthcare professionals and patients.</li><li>Attention to detail and organizational skills to manage multiple tasks simultaneously.</li></ul>Join our dedicated team as a Medical Scribe and contribute to improving patient care through precise documentation and support!Job Types: Full-time, InternshipPay: $18.11 - $19.00 per hourBenefits:<ul><li>401(k)</li><li>401(k) matching</li><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Work Location: In person

Medical Scribe/Medical Assistant

Shasta Community Health Center

<div><h1 class="jobSectionHeader">Base Pay: $22.00 -$ 32.50</h1>
<h1 class="jobSectionHeader">Schedule: M - Thurs (5:30 pm - 8 pm), Sat (9am - 1 pm)</h1>

(Temporary Position)
<h1 class="jobSectionHeader">
JOB SUMMARY</h1>
<h1 class="jobSectionHeader">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.</h1>
<h1 class="jobSectionHeader">JOB DUTIES AND RESPONSIBILITIES</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>

Optional Trainable Skills
A Scribe can be trained to handle Patient Portal tasks for your assigned provider and chart abstraction.
<h1 class="jobSectionHeader">KNOWLEDGE, SKILLS, AND ABILITIES</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">EDUCATION &amp; EXPERIENCE</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">PREFERRED QUALIFICATIONS</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> 


Shasta Community Health Center is an Equal Opportunity Employer</div>

Medical Scribe (Urgent Care) (Temporary-Part Time)

Aspen Rehab PLLC

Job Overview We are seeking a dedicated and detail-oriented Medical Scribe to join our healthcare team. As a Medical Scribe, you will play a crucial role in supporting healthcare providers by accurately documenting patient encounters in real-time. Looking for local only in Flagstaff AZ or within 20 miles given live training is needed for this position. Please do not apply if you are not local.Responsibilities<ul><li>Accurately document patient histories, and treatment plans as dictated by medical provider.</li><li>Assist healthcare providers in maintaining up-to-date electronic health records (EHR).</li><li>Ensure that all documentation complies with legal and regulatory requirements</li><li>Maintain confidentiality of patient information in accordance with HIPAA regulations</li></ul>Experience<ul><li>Excellent communication skills and the ability to work collaboratively with a medical provider</li><li>Attention to detail and ability to manage multiple tasks efficiently in a fast-paced environment.</li></ul>Join our team as a Medical Scribe and contribute to delivering exceptional patient care while gaining valuable experience in the healthcare field.Job Type: Part-timePay: $18.00 - $19.00 per hourWork Location: Remote

Dr Ashok Amin M.D.

Gastroenterology (GI) Medical Scribe &mdash; Job DescriptionPosition TitleMedical Scribe &ndash; Gastroenterology (GI)Position SummaryThe Gastroenterology Medical Scribe assists GI physicians by documenting patient encounters in real time during clinic visits, hospital rounds, consultations, procedures, and follow-up care. The scribe ensures accurate and timely electronic medical record (EMR) documentation, allowing providers to focus on patient care.Key Responsibilities<ul><li>Accompany GI physician during outpatient clinic visits and hospital rounds</li><li>Document patient history, symptoms, physical examinations, assessments, and treatment plans in the EMR</li><li>Record procedure notes for GI procedures such as colonoscopies, endoscopies, and consults</li><li>Enter orders, referrals, lab requests, and imaging requests as directed by the physician</li><li>Update patient charts, medication lists, allergies, and past medical history</li><li>Assist with chart preparation before clinic and hospital sessions</li><li>Track diagnostic results and ensure documentation completion</li><li>Coordinate with nurses, medical assistants, and hospital staff regarding documentation needs</li><li>Maintain HIPAA compliance and patient confidentiality at all times</li><li>Complete charts promptly and accurately according to clinic and hospital policies</li></ul>Required Qualifications<ul><li>High school diploma or equivalent required</li><li>Knowledge of medical terminology, especially GI terminology, preferred</li><li>Ability to learn EMR systems such as Epic, Cerner, or eClinicalWorks</li><li>Strong typing and computer skills</li><li>Excellent listening, communication, and organizational skills</li><li>Ability to multitask in fast-paced clinical and hospital environments</li></ul>Preferred Qualifications<ul><li>Pre-med, nursing, PA, or healthcare-pursing related educational background</li><li>Experience in gastroenterology, internal medicine, or hospital settings</li><li>Bilingual skills are a plus</li></ul>Work Environment<ul><li>Outpatient GI clinic</li><li>Hospitals and inpatient rounding settings</li><li>May involve standing/walking for extended periods</li><li>Fast-paced environment with direct physician interaction</li></ul>Schedule<ul><li>Full-time</li><li>May include early mornings for hospital rounds</li><li>Clinic and hospital coverage based on physician schedule</li></ul>Skills Needed<ul><li>Attention to detail</li><li>Medical documentation accuracy</li><li>Professionalism and confidentiality</li><li>Time management</li><li>Team collaboration</li><li>Ability to learn GI-specific terminology and workflows</li></ul>Sample GI Terminology Exposure<ul><li>GERD</li><li>IBS</li><li>Crohn&rsquo;s disease</li><li>Ulcerative colitis</li><li>Colonoscopy</li><li>EGD (upper endoscopy)</li><li>Liver disease</li><li>GI bleeding</li><li>Polyps</li><li>Biopsy documentation</li></ul>Pay: $16.00 - $21.00 per hourWork Location: In person

Medical Scribe and Medical Assistant

Medical Scribing Solutions

Job DescriptionWho We AreWe are a locally based medical scribing company dedicated to supporting motivated, service-driven individuals pursuing careers in healthcare. Many of our team members go on to medical school, PA school, or other advanced healthcare programs.Who We&rsquo;re Looking ForWe are seeking college students or recent graduates planning to apply to Physician Assistant, Medical, Physical Therapy, or other healthcare-related programs. The ideal candidate will demonstrate:<ul><li>Typing proficiency (minimum 50 WPM) and strong computer skills</li><li>A commitment to maintaining patient and employee confidentiality</li><li>Excellent organizational and multitasking abilities</li><li>A team-oriented mindset and adaptability in a clinical setting</li></ul>Why Join MSS?<ul><li>Proven Track Record: 93% of our medical school applicants and 100% of PA school applicants using our advising were accepted on their first attempt.</li><li>Personalized Career Support: We provide guidance to strengthen applications, highlight achievements, and balance academic demands.</li><li>Clinical Experience: Work directly alongside healthcare providers, observe patient care, and gain valuable exposure to signs, symptoms, and medical decision-making.</li><li>Paid Learning Opportunity: Consider this a paid clinical education with flexible hours designed to fit your schedule.</li><li>Team-Based Environment: Experience firsthand how healthcare professionals collaborate to deliver quality patient care.</li></ul>Responsibilities<ul><li>Document provider&ndash;patient encounters in real-time during exams and procedures</li><li>Assist providers with routine administrative tasks to support efficient care delivery</li><li>Prepare lab results, imaging reports, and patient records for review</li><li>Accurately record diagnoses, treatment plans, orders, and counseling per provider direction</li><li>Maintain accuracy and completeness of documentation through clear communication with providers</li></ul>Position Details<ul><li>Job Types: Full-time, Part-time</li><li>Pay: $11.00 &ndash; $14.00 per hour</li><li>Schedule:</li><li>8-hour shifts</li><li>Day shifts, Monday&ndash;Friday</li><li>Location: In-person</li></ul>Specialties ServedCardiology &middot; Dermatology &middot; Internal Medicine &middot; Neurology &middot; Otolaryngology (ENT) &middot; Primary Care &middot; Surgery &middot; Other specialtiesBenefits<ul><li>Flexible scheduling to accommodate school commitments</li><li>Direct, hands-on clinical experience in a supportive environment</li></ul>Note: Preparing for the MCAT? You&rsquo;re still encouraged to apply&mdash;we&rsquo;re happy to secure your position for the fall.Job Types: Full-time, Part-timePay: $12.00 - $14.00 per hourBenefits:<ul><li>Professional development assistance</li></ul>Work Location: In person

Medical Scribe - Pre-Health Undergraduate or Gap Year Experience

Greater Phoenix Psychiatric Associtaes

Full Job DescriptionMedical Scribe &ndash; Psychiatric Hospital (Pre-Med / Pre-PA Opportunity)We are seeking a highly motivated, compassionate, and detail-oriented Medical Scribe to work directly alongside a psychiatrist physician in a psychiatric hospital setting. This is an excellent opportunity for students or graduates pursuing careers in medicine, psychiatry, psychology, physician assistant studies, nursing, or other healthcare fields to gain valuable hands-on clinical experience in mental health care.Key Responsibilities:<ul><li>Document psychiatric patient encounters in real-time within the electronic health record (EHR) system</li><li>Accurately record psychiatric histories, mental status exams, assessments, diagnoses, and treatment plans</li><li>Work closely with the psychiatrist to ensure timely, accurate, and complete medical documentation</li><li>Assist with coordination and documentation of medications, admissions, discharges, consultations, and treatment updates</li><li>Communicate professionally with patients, physicians, nurses, social workers, and clinical staff</li><li>Support daily clinical workflow to enhance patient care efficiency and continuity of care</li><li>Maintain strict patient confidentiality and professionalism in a psychiatric care environment</li></ul>Qualifications:<ul><li>Strong interest in pursuing a healthcare career (Pre-Med, Pre-PA, Nursing, Psychology, or related fields preferred)</li><li>Exceptional attention to detail and ability to multitask in a fast-paced clinical setting</li><li>Excellent written and verbal communication skills</li><li>Ability to work efficiently while maintaining accuracy under pressure</li><li>Professional demeanor, emotional maturity, and compassionate patient interaction skills</li><li>Previous medical scribe or healthcare experience preferred but not required</li><li>Familiarity with EHR systems is a plus</li></ul>What You&rsquo;ll Gain:<ul><li>Direct, hands-on experience working side-by-side with a psychiatrist physician</li><li>Exposure to psychiatric evaluations, mental health diagnoses, and clinical decision-making</li><li>Valuable clinical experience for medical, PA, nursing, or graduate school applications</li><li>Mentorship and learning opportunities in psychiatry and inpatient mental health care</li><li>Experience working within a multidisciplinary hospital team environment</li></ul>Position Details:<ul><li>Monday&ndash;Friday schedule (about 8am-12pm depending on number of patients)</li><li>Competitive pay based on experience</li><li>Fast-paced, team-oriented hospital environment</li></ul>Job Type: Part-time / Full-timeWork Location: In personPay: $18.00 - $20.00 per hourMedical Specialty:<ul><li>Psychiatry</li></ul>Education:<ul><li>Associate (Preferred)</li></ul>Experience:<ul><li>Any Medical Scribing or studying to be a medical provider: 1 year (Preferred)</li></ul>Work Location: In person

Scribe to work with a Psychiatrist in a Hospital

Proscribe

<div>Description:

The scribe performs medical record documentation and clerical duties to increase provider effectiveness, efficiency, and productivity for improved patient flow and satisfaction.
To be considered, your availability must allow for you to work at least all shift times per the following shift needs. You must be able to work the full duration of one of the shift times listed. (If your schedule does not allow for you to fulfill the shift needs, please reapply at a later time once your schedule is more open).
Shift Needs:<ul><li>
Shift Need #1: Monday, Wednesday, Friday, and Saturday at Main and MSTH 0600-1500, 0800-1700, 0900-1800, 1100-2000</li><li>
Shift Need #2: Tuesday, Wednesday, Thursday, and Sunday at Main and MSTH 0600-1500, 0800-1700, 0900-1800, 1100-2000</li><li>
Shift Need #3: Wednesday through Sunday| Main, Stone Oak and MSTH 1500-0000, 1800-0200, 1800-0300, 2200-0600</li></ul>
*Locations include: Methodist Stone Oak, Methodist Children's, Methodist MST and Methodist Main in San Antonio, TX* 
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily with or without accommodation. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
Essential duties include:<ul><li>
Preparing and assembling medical record documentation/charts to support healthcare providers</li><li>
Entering the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications</li><li>
Thoroughly updating all components of the patient's medical record at the direction of the physician</li><li>
At the direction of the physician, updates all components of the patient's medical record including subjective and objective information, physical exam, and any other pertinent clinical information</li><li>
Preparing and sending all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures</li><li>
Collaborating with healthcare staff to efficiently monitor basic lab results and screening procedures</li><li>
Monitor duration of lab test and follow up as necessary</li><li>
Ensure accurate documentation in patient record</li><li>
Supporting compliance with hospital and ProScribe policies</li><li>
Understand and maintain HIPAA regulations</li><li>
Understand and maintain Joint Commission standards</li><li>
Understand applicable policies for assigned site</li><li>
Understand ProScribe policies as related to specific role</li><li>
Demonstrating professionalism through adherence to ProScribe&rsquo;s attendance policies at assigned facility</li><li>
Attendance responsibilities may vary based on provider preferences and EMR specifics</li><li>
Performing other clerical duties and tasks to improve provider productivity and clinic workflow as assigned</li></ul>
Requirements:
<ul><li>High school diploma or equivalent required</li><li>
Must be 18+ years old and authorized to work in the US</li><li>
Successful completion of a background check and drug screen</li><li>
Ability to obtain proof of vaccinations as required by specific site</li><li>
Typing speed 45+ WPM</li><li>
Ability to fluently read, write, and understand English</li><li>
Part-timeAvailable to work two shifts per week (16-24 hours per week) for a minimum of 6 consecutive months</li><li>
Full-timeAvailable to work three shifts per week (32+ hours per week) for a minimum of 12 consecutive months</li><li>
Ability to work shifts ranging from 8 to 12 hours</li><li>
Ability to understand HIPAA regulations and appropriately maintain confidential patient and client information</li></ul>
Physical and Occupational Demands:
The physical and occupational demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
In person:<ul><li>
Ability to stand with mobility for extended periods of time</li><li>
Ability to sit for extended periods of time</li><li>
Ability to view computer monitors with close vision, color vision, depth perception and ability to adjust your focus with good hand-eye coordination</li><li>
Ability to operate a computer and/or laptop through proficient typing, clicking, and viewing a monitor for extended periods</li><li>
Ability to professionally function and communicate in an emotionally-charged, stressful, and diverse environment</li><li>
Ability to operate in a fast-paced environment with potentially limited rest or break opportunities</li><li>
Position may require work at more than one location during a scheduled work week</li></ul></div>

On-Site Medical Scribe | Emergency Medicine | San Antonio, TX | Multiple Shift Times | Weekdays/ Weekends

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Medical Scribe/Medical Assistant

Medical Scribe (Urgent Care) (Temporary-Part Time)

Medical Scribe/Medical Assistant

Medical Scribe and Medical Assistant

Medical Scribe - Pre-Health Undergraduate or Gap Year Experience

Scribe to work with a Psychiatrist in a Hospital

On-Site Medical Scribe | Emergency Medicine | San Antonio, TX | Multiple Shift Times | Weekdays/ Weekends