
Administrative Medical Documentation Specialist
1 week ago
This is a medical scribe position that supports clinic efficiency, improves care continuity, and shortens turnaround time for charts, letters, and insurance-related documentation.
The Impact You Will Make- Accurately document patient encounters directly into the electronic health record (EHR) during or immediately after visits.
- Capture relevant history, objective findings, assessments, treatment plans, and outcomes in clear, structured notes.
- Use clinic templates and standards to ensure notes are billable, compliant, and ready for provider sign-off.
- Prepare and edit patient notes, visit summaries, progress reports, and letters to referring physicians.
- Maintain consistency of records across encounters and ensure timely chart updates.
- Organize and track outstanding documentation for provider review.
- Assist with documentation needed for medical necessity, insurance authorization, and claims support.
- Enter or verify coding-related details (ICD/CPT as directed) and resolve documentation gaps that impact billing.
- Coordinate with administrative staff to ensure clean claims and reduce rework.
- Perform accuracy checks for patient identifiers, visit details, and plan of care before submission.
- Adhere to Health Insurance Portability and Accountability Act (HIPAA) and clinic privacy/security protocols at all times.
- Meet same-day or agreed-upon turnaround times for chart completion.
- Communicate clearly with U.S.-based providers and administrative teams during working hours.
- Flag urgent issues, clarify missing information, and respond promptly to requests.
- Support end-of-day reconciliations and carry-forward tasks to keep workflows current.
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