Medical Scribe Specialist

Sequel Technologies; Saddar; On-site; PKR 520,000 - 780,000; Full time

Job summary

Sequel Technologies in Rawalpindi is seeking a Medical Scribe to document patient encounters in real time within an EHR. You will ensure accurate notes including HPI, ROS, exam findings, and plans, while maintaining HIPAA compliance.

The ideal candidate has MBBS or related medical training, 1–2 years of scribing or clinical documentation experience, and strong English communication to collaborate with US healthcare providers.

Qualifications

• Medical terminology, anatomy, common diagnoses, medications, and clinical documentation.
• Experience using electronic health record systems to enter and update clinical notes.
• Strong written and verbal English skills to communicate with US providers and team members.

Responsibilities

• Document patient encounters accurately and in real time in the electronic health record (EHR), including HPI, ROS, physical findings, assessment, and treatment plans.
• Enter and update clinical notes efficiently in the EHR, navigating charts to locate patient records, lab results, imaging reports, medication lists, and prior notes.
• Prepare accurate, complete notes following provider instructions and documenting only observed or directed content.
• Support order entry, referrals, and results review as directed by the provider.
• Capture documentation elements needed for accurate charge capture (chief complaint, history, exam, medical decision making, time spent).
• Coordinate with coders and billing staff to resolve documentation queries affecting claims.
• Maintain patient privacy and HIPAA compliance in all settings, including remote work.
• Proofread notes for spelling, grammar, and logical consistency before finalizing them.
• Report EHR errors and documentation concerns promptly to supervisor.
• Complete documentation within agreed turnaround times.

Skills

Medical knowledge

EHR proficiency

Attention to detail

Confidentiality

English communication

Education

MBBS or related medical degree

Job description

Location: Bahria Town Phase 7, Rawalpindi (Preference for residents of Bahria, DHA, or nearby areas)

Company Description

Sequel Technologies, a software company providing healthcare IT and medical billing services to the US market.

Responsibilities

• Document patient encounters accurately and in real time in the electronic health record (EHR), including the History of Present Illness (HPI), Review of Systems (ROS), physical examination findings, assessment, and treatment plans.
• Enter and update clinical notes efficiently in the EHR, navigating charts to locate patient records, lab results, imaging reports, medication lists, and prior encounter notes.
• Prepare accurate, complete, and well-organized clinical notes while following the provider’s instructions, documenting only what the provider observes, says, or directs.
• Support order entry, referrals, and results review only as directed by the provider.
• Capture the documentation elements needed for accurate charge capture, including chief complaint, history, exam, medical decision making, and time spent, to support correct coding.
• Coordinate with coders and billing staff to resolve documentation queries that may affect claims.
• Maintain patient privacy and comply with HIPAA requirements and organizational policies for data handling, secure system access, and confidentiality in clinical areas, over the phone, and in any remote work setting.
• Proofread notes for spelling, grammar, and logical consistency before finalizing them.
• Report EHR errors, system issues, and documentation concerns to the supervisor promptly.
• Complete documentation within agreed turnaround times, typically before the end of each clinic session or shift.

Qualifications/Skills

Required

• Medical knowledge: Good understanding of medical terminology, anatomy, common diagnoses, medications, and clinical documentation.
• Education: An MBBS or other relevant medical degree. Candidates with other relevant medical qualifications will be considered.
• Experience: A minimum of 1 to 2 years as a medical scribe, clinical documentation specialist, or clinical assistant.
• EHR proficiency: Experience using electronic health record systems to enter and update clinical notes efficiently.
• Attention to detail: Ability to prepare accurate, complete, and well-organized clinical notes while following provider instructions.
• Confidentiality: Understanding of HIPAA requirements and the importance of maintaining patient privacy.
• English communication: Strong written and verbal English skills, including listening comprehension and the ability to understand providers during patient encounters.

Preferred

• Experience with real-time or remote scribing.
• Experience working with US healthcare providers and US medical practices.
• Experience with specialty-specific documentation workflows.
• Orthopedics and Vascular Scribing experience