
Virtual Medical Scribe
23 hours ago
Medical Documentation Specialist
Job Description:A Medical Documentation Specialist plays a crucial role in ensuring the accuracy and timeliness of patient records. Working closely with healthcare providers, this individual is responsible for documenting clinical interactions in real-time, capturing accurate information, and maintaining charts and lists.
This specialist also handles administrative tasks such as templating notes and handling visit summaries, while reviewing prior records to provide context for current visits. Effective communication with providers is key to ensuring documentation meets clinical and legal standards.
Responsibilities:
- Documenting Patient Encounters: Accurately document real-time patient encounters during virtual or recorded consultations using Electronic Medical Records (EMRs).
- Capturing Accurate Information: Capture patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions accurately.
- Maintaining Charts and Lists: Update and maintain charts, medication lists, allergies, and problem lists.
- Administrative Tasks: Assist with administrative tasks such as templating notes and handling visit summaries.
- Reviewing Prior Records: Review prior records to provide context for current visits.
- Maintaining Communication: Maintain effective communication with providers for clarification and accuracy of documentation.
- Ensuring HIPAA Compliance: Ensure all documentation is HIPAA-compliant and meets clinical and legal standards.
Requirements:
- Excellent Communication Skills: Excellent verbal and written English communication skills are essential.
- Experience: At least 1–2 years of experience as a medical scribe or in a clinical documentation role is preferred.
- Familiarity with Medical Terminologies: Familiarity with medical terminologies and clinical workflows is necessary.
- Education: A healthcare-related degree is highly recommended.
- Technical Skills: Proficiency with Google Workspace and/or Microsoft Office is required. Experience with EMRs such as Epic, Cerner, or AthenaHealth is beneficial.
- Certifications: HIPAA Certification is advantageous.
- Personal Qualities: Fast and accurate typing skills, strong attention to detail, organized, and highly focused, with flexibility to work night shifts.
Benefits:
- Starting Rate: $800 monthly
- Employment Type: Independent Contractor
- Free Training
- Paid Time Offs
- HMO Coverage
- Optical Rewards
- Performance-Based Increase
- Permanent Work From Home
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