Clinical Documentation Specialist (Medical Scribe)

Intermountain Healthcare Inc.; Utah; On-site; USD 26,000 - 36,000; Full time

Benefits offered by this job

Benefits package

Job summary

Intermountain Healthcare Inc. seeks a Medical Scribe to facilitate patient flow and ensure accurate, complete medical records in the clinical setting. You will document visits, histories, exams, procedures, and physician instructions in real time.

Responsibilities include data entry, billing support, and participation in quality improvement efforts. Strong medical terminology, attention to detail, and ability to maintain confidentiality are required.

Qualifications

• Demonstrated experience with medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to understand and transcribe dictated reports.
• Proficiency with word processing, spreadsheets, databases, internet, and e-mail.
• Ability to type/input information fast and accurately.

Responsibilities

• Accurately and thoroughly document medical visits and procedures as performed by the physician.
• Document patient medical history and physical exams.
• Record procedures and treatments performed by healthcare professionals including nurses and physician assistants.
• Record physician-dictated diagnoses, prescriptions, and follow-up instructions.
• Use computer applications to maintain medical records and billing documentation.
• Maintain and secure medical records and other information.
• Facilitate timely billing by completing the necessary documentation.
• Participate in quality improvement initiatives (CQI, TQM, Lean).
• Comply with standards for medical records confidentiality.

Skills

Medical Scribe

Patient Care

Medical Billing and Coding

Clinical Documentation

Medical Terminology

Medical Knowledge

Patient Evaluations

Data Entry

Medical Writing

Medical Records Management

Education

Associate's degree or equivalent experience

Tools

iCentra

EPIC

Help2

Job description

Intermountain Healthcare Inc. seeks a Medical Scribe to facilitate patient flow and ensure accurate, complete medical records in the clinical setting. You will document visits, histories, exams, procedures, and physician instructions in real time.

Responsibilities include data entry, billing support, and participation in quality improvement efforts. Strong medical terminology, attention to detail, and ability to maintain confidentiality are required.