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.