
Clinical Documentation Specialist
1 week ago
Medical Scribe plays a crucial role in the healthcare team by documenting clinical interactions in real-time, ensuring accurate and detailed patient records.
">- Documenting real-time patient encounters during virtual or recorded consultations using Electronic Medical Records (EMRs).
- Accurately capturing patient histories, physical exam findings, diagnostic impressions, treatment plans, and follow-up instructions.
- Updating and maintaining 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 communication with providers for clarification and accuracy of documentation.
- Ensuring all documentation is HIPAA-compliant and meets clinical and legal standards.
Requirements
- Excellent verbal and written English communication skills.
- At least 1–2 years of experience as a medical scribe or in a clinical documentation role.
- Familiar 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.
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