Job Description

The Medical Scribe will work closely with healthcare providers to accurately document patient encounters, medical histories, physical examinations, and treatment plans in real-time during patient visits. This is an In-Office position. The ideal candidate will have excellent typing skills, strong attention to detail, and a background in medical terminology and healthcare documentation.

Responsibilities:

• Real-Time Documentation: Accompany healthcare providers during patient encounters to document medical histories, physical examinations, chief complaints, and treatment plans in real-time using electronic health records (EHR) or medical scribe software. Transcribe and accurately document verbal orders, instructions, and procedures provided by healthcare providers during patient visits.
• Medical Charting and Coding: Assist with medical charting and documentation, including entering patient demographics, updating medical histories, and documenting assessment findings and treatment plans in accordance with practice protocols. Ensure accurate and complete documentation of patient encounters to support medical coding, billing, and reimbursement processes.
• Communication and Collaboration: Communicate effectively with healthcare providers, clinical staff, and administrative staff to facilitate efficient patient care and documentation processes. Collaborate with healthcare providers to clarify documentation, obtain additional information, and ensure accuracy and completeness of medical records.
• Patient Education and Support: Assist with patient education by providing information on treatment plans, medication instructions, follow-up appointments, and referrals as directed by healthcare providers. Address patient inquiries, concerns, and requests for information in a professional and courteous manner.
• Quality Assurance and Compliance: Maintain confidentiality and privacy of patient health information in compliance with HIPAA regulations and practice policies. Participate in quality assurance activities, including chart audits, documentation reviews, and compliance assessments to ensure accuracy and completeness of medical records.
• Administrative Support: Provide administrative support to healthcare providers, including scheduling appointments, coordinating referrals, and completing medical forms or documentation as needed. Assist with other administrative tasks as assigned by practice management or healthcare providers.

Requirements

• High school diploma or equivalent required; Bachelor's degree or certification in medical assisting, healthcare administration, or related field preferred.
• Previous experience as a medical scribe or in a healthcare documentation role preferred.
• Strong knowledge of medical terminology, anatomy, and physiology.
• Excellent typing skills and proficiency in using electronic health records (EHR) or medical scribe software.
• Strong attention to detail and accuracy in medical documentation.
• Excellent communication and interpersonal skills, with the ability to work collaboratively in a healthcare team environment.
• Ability to maintain professionalism, confidentiality, and discretion in handling sensitive patient information.