Medical Scribe

Suvidahealthcare; Dallas (TX); On-site; USD 65,000 - 105,000; Full time

Job summary

Suvida Healthcare seeks a Clinical Informatics Specialist to collaborate with the care team, ensuring precise documentation during patient encounters and efficient EHR usage. You will scribe, record histories, exams, and plans in real time to support clinicians and patient care.

Responsibilities include chart reviews, coding (ICD-10/CPT), data integrity, and communication with providers. Strong English/Spanish skills and HIPAA compliance are essential for success.

Qualifications

• Bachelor's degree preferred in healthcare or related field.
• Minimum 2 years of clinical experience.
• Familiarity with medical terminology, anatomy, physiology a plus.
• Ability to efficiently use electronic health record (EHR) systems.
• Strong typing and computer proficiency; good written and verbal communication.

Responsibilities

• Document patient encounters in real time, including histories, exams, tests, and plans.
• Input and manage patient data in EHR systems while ensuring compliance and confidentiality.
• Review and organize patient charts for completeness and accuracy.
• Communicate with providers and team members; relay requests and follow-up instructions.
• Enter ICD-10 and CPT codes for diagnoses and services.
• Liaise between coding team and providers to resolve documentation queries.
• Prepare information for morning huddles by researching patient data.
• Monitor quality metrics; identify gaps and contribute to improvement.
• Analyze population health data to aid risk stratification and enrollment in programs.
• Stay updated on evidence-based protocols and share findings with the team.
• Maintain HIPAA-compliant handling of patient data.

Skills

Clinical documentation

EHR proficiency

ICD-10 coding

CPT coding

Data entry

HIPAA/compliance

Bilingual English/Spanish

Education

Bachelor’s degree in healthcare

Tools

EHR software

Job description

Position Summary

The Clinical Informatics Specialist (CIS) collaborates with Suvida Healthcare primary care providers and assumes a vital role within the Care Team. The primary focus is on ensuring the accuracy and efficiency of medical documentation during patient encounters. Working closely with primary care providers, the CIS scribes and records medical histories, physical examinations, diagnostic tests, treatment plans, and other pertinent information into electronic health record (EHR) systems. The CIS’s support empowers healthcare professionals to allocate more time to patient care while maintaining comprehensive and precise patient records. Essential key responsibilities consist of but are not all inclusive:

Responsibilities

• Patient Encounter Documentation: Accompany healthcare providers during patient visits and accurately document all relevant medical information, including medical histories, physical examinations, diagnostic tests, and treatment plans in real-time.
• EHR Management: Navigate and proficiently utilize electronic health record (EHR) systems to input and manage patient data, ensuring that all documentation adheres to compliance and confidentiality standards.
• Chart Review: Regularly review and organize patient charts, ensuring completeness and accuracy of information, and addressing inconsistencies or discrepancies.
• Effective Communication: Act as a liaison between healthcare providers and other team members, facilitating the exchange of important information, requests, and follow-up instructions.
• Data Entry and Coding: Enter accurate ICD-10 and CPT codes for diagnoses, procedures, and services provided during patient encounters.
• Liaison for Documentation Queries: Serve as a liaison between the coding team and providers to ensure the timely resolution of documentation queries.
• Morning Huddle Preparation: Conduct thorough research of patients' historical charts and external data to enhance the morning huddle presentation.
• Quality Metrics Management: Oversee measurement, analysis, and reporting of healthcare quality metrics. Identify and close gaps in care to ensure optimal outcomes.
• Population Health Optimization: Analyze population health and coding strategies to enhance patient stratification, identifying at‑risk patients and assisting in enrolling them in chronic care management protocols.
• Evidence-Based Research: Stay updated on evidence‑based medical protocols and provide revised data to the care team.
• Maintain Confidentiality: Adhere to strict patient privacy and confidentiality regulations (e.g., HIPAA) and ensure that all patient data is handled with the utmost discretion.

What You’ll Bring

• Bachelor’s degree in healthcare or related field, preferred.

Education, Experience, Licensure, or Certification Requirements

• Minimum of 2 years of clinical experience.
• Familiarity with medical terminology, anatomy, and physiology is a plus.
• Prior experience as a Medical Scribe is preferred, though not obligatory.
• Ability to efficiently use electronic health record (EHR) systems.
• Strong typing skills and advanced computer proficiency.
• Effective written and verbal communication skills.
• Ability to thrive in a fast‑paced clinical environment with a commitment to accuracy.
• Strong organizational skills, effective time management, and problem‑solving capabilities.
• Willingness to move between Neighborhood Centers as needed.
• Proficiency in both English and Spanish is required.

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any type with regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.