Clinical Documentation Specialist (Medical Scribe)

Integrity Care Group; Enid (OK); Hybrid; USD 38.000 - 52.000; Vollzeit

Zusammenfassung

Integritycaregroup is seeking a Clinical Support Specialist to assist on-staff providers with documentation of patient encounters in the EMR using AI tools. The role emphasizes accuracy, compliance, and timely entry of orders, results, and discharge instructions.

You will collaborate with nurses, physicians, and administrative staff to maintain efficient patient flow, proper documentation, and clear communication with patients about care updates and next steps.

Qualifikationen

• Must have basic computer skills and EMR familiarity.
• Ability to read and write medical terminology accurately.
• Flexibility to work all shifts and assist with patient transport.
• Detail-oriented with strong communication with patients and staff.

Aufgaben

• Document encounters in EMR using AI-enabled tools.
• Review AI-generated notes for completeness and clarity.
• Enter lab, imaging, and medication orders for provider review.
• Process lab results and discharge documentation in the EMR.
• Assist with patient discharge workflows and instructions.
• Collaborate with providers, nurses, and staff to improve clinic flow.

Kenntnisse

PC skills

Medical terminology

Shift flexibility

Patient transport

Interpersonal communication

Ausbildung

High School Diploma

BLS Certification (current)

Jobbeschreibung

Description

Position Summary:

The Clinical Support Specialist will participate in the documentation of healthcare records for patients under the direction of on-staff providers while maintaining compliance with clinic, State, and National policies, procedures, rules, and regulations.

Duties and Responsibilities:

• Support the creation of accurate and timely clinical documentation during patient encounters using AI-enabled documentation tools and the electronic medical record (EMR), including HPI, ROS, physical exam findings, and provider observations.
• Review AI-generated encounter documentation for completeness, clarity, and internal consistency and flag discrepancies or items requiring provider clarification.
• Prepare clinical documentation for provider review and signature.
• Enter and queue laboratory, imaging, medication, and prescription orders for provider review and approval.
• Process and document lab results, diagnostic testing, and provider interpretations within the electronic medical record (EMR).
• Assist with patient discharge workflows, including entering diagnoses, preparing discharge instructions, printing patient paperwork, work notes, and school excuses, and completing discharge documentation in the EMR
• Support patient flow by updating patient status, facilitating timely discharges, and helping reduce door-to-door visit times.
• Communicate with patients regarding wait times, test results, care updates, and provider-directed follow-up information.
• Assist with pharmacy management activities, including updating pharmacy information and supporting prescription processing.
• Manage provider inbox tasks, telephone encounters, patient callbacks, and other routine communications.
• Enter procedure documentation, medication administration records, injection orders, and EKG interpretations as directed by providers.
• Assist clinical staff with laboratory operations and specimen processing when needed.
• Answer incoming clinic phone calls and route requests appropriately.
• Collaborate with providers, nurses, technicians, and administrative staff to improve clinic efficiency and patient experience.
• Serve as a workflow support resource, allowing providers to focus on direct patient care while maintaining timely and accurate documentation.
• Monitor outstanding clinical documentation, orders, results, patient communications, and other provider-directed tasks and facilitate timely completion or escalation to the appropriate team member.
• Additional duties as assigned

Requirements

Education:

• High School Diploma or equivalent.
• Licenses/Certification:
• Must obtain and maintain a current certification in BLS.

Experience:

• Healthcare experience preferred.

Skills:

• PC skills or applicable computer experience.
• Ability to accurately read and write medical terminology.
• Ability to work all shifts.
• Ability to escort or transport patient by wheelchair or stretcher.
• Detail-oriented with excellent interpersonal communication skills.

Working Conditions:

• May be exposed to/occasionally exposed to patient elements.
• Subject to varying and unpredictable situations and interruptions.
• Occasionally subjected to irregular hours.
• Occasional pressure due to a fast-paced environment.
• The position may require lifting, carrying, or pushing equipment or patients.

Physical Requirements:

• Must be able to see with corrective eyewear.
• Must be able to hear clearly with assistance.
• May be exposed to infectious and contagious diseases.
• May be in contact with patients under a wide variety of circumstances.
• Able to handle emergency or crisis situations.
• Will be required to wear protective equipment as necessary.
• Ability to escort or transport patient by wheelchair or stretcher
• Frequently: Sitting, walking, standing.
• Occasionally: Bending, squatting, climbing, kneeling, twisting, lifting, carrying, pushing, traveling.
• Ability to lift 15-20 pounds