
Clinical Documentation Specialist
1 day ago
This role is ideal for a detail-oriented professional with experience in medical documentation and administrative tasks.
You will work closely with an orthopedic surgeon, documenting patient encounters in real-time and managing clinical information in the electronic medical record (EMR). Outside of scribe duties, you will assist with insurance-related tasks, pain log tracking, and various administrative functions to support efficient clinical operations.
Responsibilities:- Medical Scribe:
- Accompany the surgeon during patient visits and document:
- History of present illness
- Physical exam findings
- Imaging reviews (MRI, CT, X-rays)
- Diagnoses and differential diagnoses
- Treatment plans, surgical protocols, and follow-up instructions
- Accurately transcribe orthopedic and spine-specific terminology and procedures
- Update EMR records, including lab/imaging orders and prescriptions
- Draft referral letters, patient education materials, and pre-surgical documents
- Maintain accurate, HIPAA-compliant patient records
- Coordinate with clinical staff to ensure documentation supports seamless care
- Accompany the surgeon during patient visits and document:
- Administrative Support:
- Contact patients and review post-procedure pain logs; update documentation and track data accurately
- Conduct insurance verification and obtain prior authorizations
- Generate accurate payment estimates using internal tools and insurance data
- Explain insurance coverage and cost estimates clearly to patients
- Prepare and manage email correspondence and documentation
- Handle data entry, reporting, and coordination with staff as needed
- At least 1 year of experience scribing for an orthopedic or spine surgery team
- Strong knowledge of medical terminology related to orthopedics and spine
- Familiarity with EMR platforms (preferably Athena Health)
- Ability to follow a provider's workflow in real-time with accuracy and discretion
- Experience with insurance verification and pre-authorizations
- Comfortable with cost estimation and patient billing discussions
- Strong written and spoken English skills (for patient communication)
- Excellent organization, time management, and attention to detail
- Ability to manage confidential information with professionalism and care
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