
Clinical Documentation Specialist
6 hours ago
A medical scribe plays a vital role in healthcare by accurately documenting patient interactions and clinical information.
This enables healthcare providers to focus on delivering high-quality care.
Key Responsibilities:- Document real-time patient encounters using electronic medical records (EMRs) such as Epic, AthenaNet/AthenaHealth, Cerner, or NextGen.
- Capture accurate and detailed patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- Maintain up-to-date charts, medication lists, allergies, and problem lists.
- Assist with administrative tasks, including templating notes and handling visit summaries.
- Review prior records to provide context for current visits.
- Foster communication with providers to ensure accuracy and completeness of documentation.
- Ensure all documentation meets HIPAA standards and clinical requirements.
- Demonstrate strong attention to detail and discretion when handling sensitive patient data.
- Excellent verbal and written English communication skills.
- 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.
- Proficiency in Google Workspace and/or Microsoft Office.
- Experience with EMRs such as Epic, Cerner, or AthenaHealth is an asset.
- HIPAA Certification is an asset.
- Fast and accurate typing skills.
- Strong attention to detail.
- Organized and highly focused.
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