
Clinical Documentation Specialist
9 hours ago
A medical scribe is a crucial member of the healthcare team, responsible for accurately documenting patient interactions in real-time.
Main Responsibilities:- Documenting patient encounters during virtual or recorded consultations using Electronic Medical Records (EMRs).
- Capturing detailed patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- Updating and maintaining accurate charts, medication lists, allergies, and problem lists.
- Assisting with administrative tasks such as templating notes and handling visit summaries.
- Reviewing prior records to provide context for current visits.
- Maintaining effective communication with providers for clarification and accuracy of documentation.
- Ensuring all documentation is HIPAA-compliant and meets clinical standards.
- Excellent verbal and written English communication skills.
- At least 1–2 years of experience as a medical scribe or in a clinical documentation role.
- Familiarity with medical terminologies and clinical workflows.
- A healthcare-related degree is highly preferred.
- Proficient with Google Workspace and/or Microsoft Office.
- Experience with EMRs such as Epic, Cerner, or AthenaHealth is a plus.
- HIPAA Certification is a plus.
- Fast and accurate typing skills.
- Strong attention to detail.
- Organized and highly focused.
- Open to working night shifts.
This position offers a unique opportunity to contribute to the delivery of high-quality patient care while developing valuable clinical documentation skills. We are looking for a motivated individual who can work effectively in a fast-paced environment and maintain accurate records.
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